Comorbid Conditions

• Addictive Personality Disorder (APD)
• Antisocial Personality Disorder (ASPD)
• Anxiety
• Asperger’s Syndrome
• Attachment Disorders / Reactive Attachment Disorder (RAD)
• Auditory Processing Disorder (APD)
• Autism Spectrum Disorder (ASD)
• Bi-Polar Disorder (PD)
• Borderline Personality Disorder (BPD)
• Conduct Disorder (CD)
• Depression
• Developmental Coordination Disorder (DCD)
• Disruptive Mood Dysregulation Disorder (DMDD)
• Dysgraphia
• Dyslexia
• Eating Disorders (ED)
• Enuresis
• Executive Function Difficulties
• Fine & Gross Motor Difficulties
• Gut Issues
• Non-Verbal Learning Disabilities (NVLD)
• Obsessive Compulsive Disorder (OCD)
• Oppositional Defiant Disorder (ODD)
• Post-Traumatic Stress Disorder (PTSD)
• Rejection Sensitive Dysphoria (RSD)
• Schizophrenia
• Seizure Disorders
• Sensory Processing Disorder (SPD)
• Sleep Problems
• Slow Processing Speed
• Specific Learning Difficulties (SLD)
• Speech & Language Disabilities
• Socialisation Issues
• Substance Use Disorder (SUD)
• Tic Disorder / Tourette Syndrome
• Written Language Disorder

People with ADHD have a greater propensity for developing Addictive Personality Disorder.

This not only relates to addiction to substances, but may also include addictive behaviours such as gambling, video games, and internet use.

A study compared the behaviour of ADHD and non-ADHD children playing video games. The ADHD children were more vulnerable to developing addictive tendencies, particularly for a specific category of games called massively multiplayer online role-playing games (MMORPG).

This propensity to addictive behaviour in ADHD is closely related to impulsivity, a need for immediate feedback, and stimulating the dopamine receptors.

Identifying childhood predictors of adult ASPD as soon as possible is essential to providing early intervention.

Kids with ADHD are three times more likely to have an anxiety disorder than kids who don’t have ADHD.

Some studies put the rate of anxiety among children with ADHD at 18% or even higher.

Because anxiety is such a common co-morbidity of ADHD, and increasingly common in the general population, it deserves its own page here.

For a short period of time (1994–2013) Asperger’s Syndrome was listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). It was one of five Pervasive Developmental Disorders and part of the Autism Spectrum. It was commonly used as another term for mild or high-functioning autism.

Officially, practitioners can no longer diagnose an individual with Asperger’s Syndrome. Since 2013, the official diagnosis is Autism Spectrum Disorder, which has a severity level between one and three based on their need for support, with 1 being the lowest support needs.

Many people already diagnosed with Asperger’s wish to maintain that diagnosis and label, as there is an existing community and supports for that diagnosis, and many support groups and clinicians still use the term, even if the American Psychiatric Association does not.

People previously diagnosed with Asperger’s are very different from those diagnosed with the more severe forms of autism but are now grouped together under the single category of Autism Spectrum Disorder. This means people with very severe challenges, who are non-verbal, intellectually challenged and require significant support to perform everyday tasks, are now included in the same category as those who may be graduating university but have social and sensory difficulties.

ADHD and Asperger’s share many similarities, and professionals may find it tricky to distinguish the two. Both conditions involve difficulties with executive functioning and information processing. Sometimes children and adults are misdiagnosed with one or other condition, but it is also possible to have both diagnoses at once.

The similarities between Asperger’s and ADHD include:

• Impulsivity
• Distractibility
• Inattentiveness
• Delayed social skills
• Sensitivity to sound, light and texture
• Problems following directions
• Tantrums
• Learning problems
• Problems with coordination
• Difficulty making and keeping friends
• High intelligence
• May be anxious

Not forming proper attachments or having an insecure attachment with a primary caregiver is a well-known risk for externalised behaviours during childhood.

Lack of attachment may result for a number of reasons including post-natal depression, substance abuse and general neglect.

If a child suffers emotional or physical trauma or maltreatment, this creates psychoneurophysiological effects, which may take the form of central nervous system hyper-arousal, hyper-vigilance, elevated cortisol levels and more.

In many respects, there is an overlap between the symptoms of ADHD and attachment disorder where difficulties regulating emotions and difficult temperament are common to both.

Attachment issues in children cause symptoms such as:

• Mood lability
• Depression
• Anxiety
• Distractibility
• Aggression
• Poor cause-and-effect thinking
• Anxiety
• Distrust of oneself and others
• Feeling helpless and hopeless
• Feeling unloved, worthless, rejected, and abandoned
• Perceiving the world as unsafe

Reactive Attachment Disorder (RAD)

RAD is a Post-Traumatic Stress Disorder (PTSD) of infancy and toddlerhood. Children with RAD have persistent symptoms of fear, which may lead to increased arousal, heart rate, startle responses, and sleep disturbance. When they encounter a fearful situation, defiance, opposition and overt resistance may occur. Avoidance of further pain becomes a primary motive and they may become calculating and devious. They will often have low self-esteem and poor relationships with their peers.

Auditory Processing Disorder (APD) and ADHD are two very different issues that look extremely similar and may be mistaken for each other and misdiagnosed.

APD is a brain-based condition that makes it hard to process what the ear hears, such as recognising subtle differences in the sounds that make up words.

APD impacts language-related skills, such as receptive and expressive language.

Symptoms of APD include:

• Seems “tuned out” due to not understanding what’s being said
• Seems forgetful
• Struggles to follow conversations/respond to spoken questions
• Frequently asks people to repeat what they’ve said
• Often responds with “huh?” or “what?”
• Has trouble following directions and spoken instructions
• May not speak clearly
• Confuses similar sounds, such as “three” instead of “free”
• Has trouble with rhyming
• Easily distracted by background noise/loud and sudden noises
• Struggles with activities that involve listening comprehension
• May prefer to read stories rather than listen to them read aloud
• May miss social cues due to having to focus so hard on understanding the actual words being said
• May not pick up on sarcasm/non-verbal forms of conversation
• May avoid socialising or want to be alone during gatherings because keeping up with conversation can be exhausting and stressful

The DSM V officially recognises Autistic Spectrum Disorder (ASD) as a co-morbidity of ADHD and classifies it under ‘Neurodevelopmental Disorders’.

Up to 58% of children with ASD also have an ADHD diagnosis.

Having both diagnoses generates additional challenges, making it vital to assess for both conditions.

The symptoms of ASD can range widely in severity and can include:

• Avoids eye contact and/or physical contact
• Difficulties with social skills
• May be verbally advanced, but finds non-verbal cues challenging
• Difficulty understanding their own and other people’s feelings
• Has delayed speech (or no speech) or repeats phrases over and over
• Dislikes changes in routine
• Is constantly moving, fidgeting, picking up and fiddling with everything
• Has sensory processing issues
• Is prone to meltdowns, anxiety, frustration, or communication difficulties
• Self-soothes using excessive body movements (stimming)
• Has obsessive interests

ADHD and Bipolar Disorder (BD) commonly occur together, making it difficult to differentiate between them. Up to 20% of BD cases co-occur with ADHD.

The main point of difference is that the symptoms of ADHD are continuous, whereas BD is more cyclical in nature.

BD results in dramatic mood swings, ranging from extreme highs in energy levels and a sense of euphoria to extreme lows of depression, hopelessness, and low energy levels. These mood swings are irregular, alternate with periods of normal mood and function, and can occur relatively independent of outside influences.

There are some similarities and overlap in symptoms — both may include:

• Hyperactive or restless behaviours
• Distractibility
• Poor concentration
• Impulsivity
• Racing thoughts
• Sleep disturbances
• Poor social relationships
• Feelings of anxiety, depression, frustration, and self-doubt
• Can impact daily functioning

It is important to note that BD can present with less clearly defined cycles before puberty.

Borderline Personality Disorder (BPD) and ADHD symptoms overlap to a degree, as both disorders share deficits in attention, impulsivity, and emotional dysregulation.

People with BPD have persistent difficulties in regulating their emotions and relating to other people, and typically experience some — but not necessarily all — of these symptoms:

• Intense mood swings including anxiety, anger, or depression
• Tumultuous interpersonal relationships
• Fluctuation between idealising and devaluing others
• Fear of being alone
• Unstable and distorted self-image or sense of self
• Feeling neglected, alone, misunderstood, chronically empty, or bored
• Feelings of self-loathing and self-hate
• Self-harm, such as cutting, as a coping mechanism
• Suicidal thoughts or suicide attempts
• Impulsive and risky behaviour
• Difficulty compromising
• Paranoid thoughts in response to stress

Since ADHD presents earlier than BPD, ADHD might be either a risk factor or an initial stage in the development of BPD, or in the reinforcement of its symptoms.

The co-morbid condition of Conduct Disorder (CD) occurs in some children with ADHD. CD has a prevalence of 2–9% in the general population, and ADHD is co-morbid in around one-third of cases.

A child or teenager who repetitively and persistently displays patterns of behaviour, whereby the basic rights of others or major societal norms are violated, may be at risk of having CD.

The typical behaviours fall into four main areas:

• Aggressive conduct causing or threatening physical harm to others
• Aggressive conduct causing or threatening physical harm to animals
• Non-aggressive conduct — property loss/damage, deceitfulness, or theft
• Repetitive serious violations of rules

Specific Symptoms of CD:

Aggression to people and animals

• Frequent bullying, threatening, or intimidating others
• Frequent initiation of physical fights
• Use of a weapon able to cause serious physical harm to others
• Physical cruelty to people and/or animals
• Stealing while confronting a victim
• Forcing someone into sexual activity

Destruction of property

• Deliberate fire setting with the intention of causing serious damage
• Deliberately destroying others’ property (other than by fire setting)

Deceitfulness or theft

• Breaking into someone else’s house, building, or car
• Frequently lying to obtain goods or favours or to avoid obligations
• Stealing items of non-trivial value without confronting a victim

Serious violations of rules

• Frequently stays out at night despite parental prohibitions, before age 13
• Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
• Frequent truanting from school, beginning before age 13

If three or more of the above criteria have occurred in the past 12 months, with at least one present in the past six months, CD could be a possibility and professional help should be sought.

The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational functioning.

Sub-Types of CD

Childhood-Onset Type

Onset of at least one criterion characteristic of CD prior to age 10 years.

Adolescent-Onset Type

Defined by the absence of any criteria characteristic of CD prior to age 10 years.

If the individual is age 18 years or older, criteria are met for Antisocial Personality Disorder.

CD is one of a group of behavioural disorders known collectively as Disruptive Behaviour Disorders, which include Oppositional Defiant Disorder (ODD) and ADHD.

Early intervention and treatment are important, since children with untreated CD are at increased risk of developing a range of problems during their adult years including substance use, personality disorders, and mental illnesses.

It is vitally important for the adults/authority figures to handle children with CD appropriately. There are great ideas in the Dr Ross Greene book The Explosive Child or Lost at School. Dr Greene believes that disruptive and challenging behaviours are a result of a child being unable to meet expectations due to lagging skills, and these lagging skills must be investigated and accommodated. He suggests a child may be developmentally delayed with regard to flexibility, adaptability, and frustration tolerance, or lack crucial cognitive and emotional skills. If they have ADHD, they will have problems with executive functioning skills relating to planning, initiating, and carrying out actions, which can lead to the development of CD.

On the other hand, Dr William Walsh believes that disruptive behaviour can be caused by certain nutrient deficiencies or overloads, such as excess copper, and can be treated with nutrient therapy.

Children with ADHD are five times as likely to have depression as children who don’t have ADHD.

Around 14% of children with ADHD also have depression.

Children diagnosed with depression are at a higher risk for also having ADHD.

Because depression is a serious and common co-morbidity, it deserves its own page here.

The comorbidity of Developmental Coordination Disorder (DCD) and ADHD is as high as 50%.

DCD is a neurodevelopmental and chronic physical health condition with persisting motor problems, which restrict a child’s ability to perform daily activities such as tying shoelaces and writing, as well as participating in physical activities with peers. Dyslexia and poor handwriting are often associated with DCD.

Lower confidence in their physical ability to participate in peer activities leads to children with DCD reporting fewer friendships and experiencing more bullying.

Practitioners should incorporate screening for DCD when evaluating students with a suspected ADHD diagnosis.

Disruptive Mood Dysregulation Disorder (DMDD) was a new diagnosis in the DSM-V in 2013.

DMDD is highly co-morbid with ADHD, with one study finding that 87% of children with DMDD also had ADHD.

DMDD is characterised by chronic dysphoria, with a minimum of three severe anger episodes per week over a period of a year. These anger episodes are associated with severe and persistent irritability.

<p>Up to 50% of children with ADHD may also have dysgraphia — a condition that affects their ability to organise numbers and letters and causes difficulties in keeping words on a straight line.</p>

Roughly 40% of children with ADHD also have dyslexia.

Symptoms can seem to overlap as children with dyslexia may fidget or act out in class because of frustrations over reading and writing, and ADHD can make it difficult to focus during reading or other activities.

Dyslexia is the most common learning issue and although it’s not clear what percentage of kids have it, some experts believe the number is between 5–10%.

Dyslexia is a neurobiological specific learning disability characterised by difficulties with accuracy and fluency in word recognition and poor spelling and decoding abilities.

Secondary problems may include issues in reading comprehension and reduced reading experience, which can affect growth in vocabulary and background knowledge.

Dyslexia impacts learning but it is not an indicator of intelligence.

Children with dyslexia may have trouble answering questions about something they’ve read, but when it’s read to them, they may have no difficulty at all.

Dyslexia can create difficulty with other skills such as writing and maths.

Dyslexia is a lifelong condition but there are supports, teaching approaches and strategies to help overcome the challenges.

Dyslexia can also impact other areas too, such as social interaction, memory and emotional regulation.

Here are some common signs of dyslexia:

Pre-school

• Trouble recognising whether two words rhyme
• Struggles with taking away the beginning sound from a word
• Struggles with learning new words
• Has trouble recognising letters and matching them to sounds

Primary School

• Trouble taking away middle sounds from words or blending several sounds
• Often doesn’t recognise common sight words
• Studies how to spell words but quickly forgets
• Difficulties with word problems in maths
• Makes frequent spelling errors
• Frequently has to re-read sentences and passages
• Reads at a lower academic level than how they speak

High School

• Frequently misses small words when reading aloud
• Reading at below expected grade level
• Strong preference for multiple-choice questions over written answers

In a study, patients with ADHD had a 1.82 times greater risk of developing an easting disorder compared to those without ADHD.

Bulimia nervosa and binge eating disorder, which are associated with impulsive behaviours, are the most frequently found in those with ADHD.

Eating can become a way of managing anxiety, fatigue or inner restlessness when under-stimulated, and so on.

Different studies have hypothesized about the link between obesity and ADHD.

One hypothesis is that dopamine comes into play in both conditions, thus linking them together.

Dopamine levels in the brain increase when food is present. Dopamine is linked to the reward system, causing a person to feel happy when there is an increase in levels. By activating the dopaminergic pathways, eating becomes a pleasurable task.

As those with ADHD have lower dopamine levels, any action that increases the dopamine levels, such as eating, will be appealing for those with ADHD. Because of the satisfaction that comes from eating, those with ADHD may use food to self-medicate and increase dopamine levels. This overeating can lead to obesity if not monitored.

Enuresis is defined as the failure of voluntary control of the urethral sphincter.

Bedwetting affects 15–20% of the child population, but children with ADHD have a 2.7 times higher incidence of enuresis and a 4.5 times higher incidence of daytime enuresis. It is not currently known why children with ADHD are more prone to this issue. Some researchers believe it may be because both conditions are linked to a delay in the development of the central nervous system, or that children with ADHD find it more difficult to pay attention to their bodily cues.

If this is happening to your child, seek advice from your GP in the first instance.

Executive Function Difficulties refers to a weakness in key mental skills responsible for memory, organisation, attention, time management and flexible thinking.

Children with ADHD also struggle with these skills, but the difference is that ADHD is an official diagnosis whereas Executive Functioning Difficulties is not.

Many children with Learning Difficulties also have Executive Functioning Difficulties or struggle with one or more of these key skills but may not be diagnosed with ADHD.

Symptoms include:

• Has a hard time paying attention
• Has difficulty with self-control
• Has trouble managing emotions
• Has difficulty holding information in working memory
• Has trouble switching easily from one activity to another
• Has trouble getting started on tasks
• Has problems organising his time and materials
• Has difficulty keeping track of what he’s doing
• Has difficulty completing long-term projects
• Has trouble with thinking before acting
• Is easily distracted and often forgetful
• Has trouble waiting his turn
• Has problems remembering what he’s been asked to do

Gross motor skills are large movements, such as running.

Fine motor skills are small movements, such as writing.

Researchers report more than 50% of children with ADHD also have problems with gross and fine motor skills.

As a result, many studies have linked ADHD with poor handwriting, which can make it hard for them to write quickly and clearly. Their work may be labelled as messy and may lead to feelings of frustration, avoidance of schoolwork and low self-esteem.

Poor handwriting can also be a sign of other developmental disorders such as:

• Developmental Coordination Disorder
• Written Language Disorder
• Dysgraphia

A good Occupational Therapist will help to pinpoint exactly what the problem is, and special motor skills training might help your child develop better fine and gross motor coordination.

Children with ADHD are significantly more likely to suffer from digestive complaints such as chronic constipation and faecal incontinence than those without ADHD. A study of more than 700,000 children found that among children with ADHD the incidence of constipation was nearly tripled and faecal incontinence increased six-fold compared to children without ADHD.

Faecal incontinence is a severe form of constipation where the constipation worsens over time, causing faecal matter to overflow and leak out. Some suggest children with ADHD have lost the normal cue to empty their bowels or become distracted because of their ADHD, and this leakage occurs as a result. However, faecal incontinence can also occur in those suffering chronic constipation who don’t have ADHD.

Many children, especially teenagers, won’t discuss their toilet habits or what their stool looks like with you — but you need to know! Often children become used to the way things are and accept them as normal when they are not.

If you notice your child is suffering from constipation, first steps are to:

• Increase fibre (if constipation not too severe)
• Drink more water
• Get plenty of exercise
• Allow a regular, un-rushed time for children to go to the toilet
• Use a toilet step such as the Aussie Squatter, which is critical for providing the correct posture for elimination, particularly for children who are smaller and therefore sit on the toilet with their feet swinging in mid-air
• Increase intake of Vitamin C or Magnesium
• Avoid the prolonged use of laxatives – find the root cause of the problem

If these initial steps don’t improve the situation you should see an integrative GP or naturopath who is experienced in treating the root cause of constipation, which may be caused by gut dysbiosis, SIBO or a food intolerance. Identifying and rectifying any gut issues is a vital step in creating strong foundations for brain health and mental wellbeing. Never simply accept that poor digestive function is normal or ‘just the way you are’ or a diagnosis of IBS. There is always a cause which should never be overlooked. We are increasingly recognising the microorganisms in our intestines – the gut micro biome – and their impact on human health, including brain functioning. For example, ADHD is a neurodevelopmental disorder associated with abnormalities in dopamine neurotransmission and deficits in reward processing so a study that showed there was a lesser amount of the bacteria associated with dopamine precursor synthesis in those with ADHD than in those without ADHD should be noted.

Non-verbal Learning Disabilities (NVLD) often co-occur with ADHD. Both can impact on learning and social skills, but although some of their symptoms are similar, there are some important differences between them.

NVLD is a brain-based learning issue affecting social and spatial skills, which can then impact on maths skills too.

Signs include some but not all:

• Talks a lot
• May interrupt people due to misread social clues such as body language
• Seems oblivious to people’s reactions
• Doesn’t get sarcasm and jokes
• Acts in socially inappropriate ways
• Stands too close to people
• May have poor balance/coordination and appear physically awkward
• Easily memorises information but may not know why it’s important
• Has trouble adjusting to change; can be inflexible
• May avoid or be fearful in new situations

These social issues mean making and keeping friends is challenging and the feelings of social rejection can impact self-esteem.

Children with Obsessive Compulsive Disorder (OCD) have ADHD in 33% of cases.

Obsessive Compulsive Disorder (OCD) is a serious anxiety-related condition where a person experiences frequent intrusive and unwelcome obsessional thoughts, often followed by repetitive compulsions, impulses or urges.

OCD presents itself in many guises and extends beyond the common perception that OCD is merely hand washing or checking light switches.

In general, OCD sufferers experience obsessions, which take the form of persistent and uncontrollable thoughts, images, impulses, worries, fears or doubts. These obsessions are often intrusive, unwanted and disturbing, significantly interfering with the ability to function on a daily basis, as they are incredibly difficult to ignore.

People with OCD usually understand their obsessional thoughts are irrational but believe the only way to relieve the anxiety caused by them is to perform compulsive behaviours, often to prevent perceived harm happening to themselves or, more often than not, to a loved one.

Compulsions are repetitive, physical behaviours and actions or mental thought rituals that are performed over and over again in an attempt to relieve the anxiety caused by the obsessional thoughts.

Avoidance of places or situations to prevent triggering these obsessive thoughts is also considered to be a compulsion.

Typically, OCD falls into one of four main categories:

• Checking
• Contamination/Mental Contamination
• Hoarding
• Ruminations/Intrusive Thoughts

To some degree, most OCD-type people probably experience symptoms at one time or another. However, OCD itself can have a totally devastating impact on a person’s entire life, from education, work and career to social life and personal relationships.

The key difference distinguishing little quirks from a clinical diagnosis of OCD is when the distressing and unwanted experience of obsessions and compulsions impacts significantly on a person’s daily life.

OCD is diagnosed when the obsessions and compulsions:

• Consume excessive amounts of time (approx. 1 hour +)
• Cause significant distress and anguish
• Interfere with daily functioning at home, school or work, including social activities and family life and relationships

OCD is a chronic but very treatable medical condition. Most people can learn to stop performing their compulsive rituals and to decrease the intensity of their obsessional thoughts through Cognitive Behavioural Therapy (CBT).

Although treatment differs for ADHD and OCD, they should take place simultaneously.

Current research suggests that symptoms of OCD have been associated with PANDAS – at least in some cases.

PANDAS results from the effect of the body’s own immune system’s antibodies attacking parts of the brain. PANDAS is a little-known illness resulting in the sudden onset of mental health issues. PANDAS is an acronym for Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS).

The onset of PANDAS usually occurs following an ear, nose or throat (ENT) infection from Group A Beta Haemolytic Streptococcus (GABHS).

GABHS antibodies in some cases can damage parts of the brain, resulting in a range of behavioural disorders such as OCD, Oppositional Defiant Disorder, Tourette’s, ADHD and even psychosis.

The co-morbid condition of Oppositional Defiant Disorder (ODD) occurs in around a third to a half of children with ADHD.

ODD behavioural problems at a young age may predispose children to bullying involvement in early primary school.

Most children can be difficult and challenging at times, and the difference between an emotional or strong-willed child and one with ODD can be hard to distinguish. Oppositional behaviour can also be perfectly normal at certain developmental stages, such as toddler tantrums or during adolescence. However, if your child or teen persistently displays tantrums, argumentative and angry behaviour, or disruptive behaviour toward you and other authority figures, he or she may have Oppositional Defiant Disorder (ODD).

ODD almost always develops before the early teen years, with signs generally beginning before age 8, although sometimes it may develop later. Symptoms tend to begin gradually and worsen over months or years.

Behaviours associated with ODD:

• Negativity
• Defiance
• Disobedience
• Hostility directed toward authority figures

ODD symptoms may include:

• Having temper tantrums
• Being argumentative with adults
• Refusing to comply with adult requests or rules
• Deliberately annoying other people
• Blaming others for mistakes or misbehaviour
• Becoming annoyed easily
• Feeling angry and resentful
• Acting spitefully or vindictively
• Acting aggressively toward peers
• Finding it difficult to maintain friendships
• Having academic problems
• Lacking self-esteem
• Not recognising behaviour as defiant
• Believing unreasonable demands are being made

For a diagnosis to be made, symptoms and behaviours must:

• Be persistent
• Have lasted at least 6 months
• Be disruptive to the home or school environment

Up to 30% of children diagnosed with ODD may go on to develop Conduct Disorder.

It is vitally important for adults and authority figures to handle children with ODD appropriately. Dr Ross Greene, author of The Explosive Child and Lost at School, believes that disruptive and challenging behaviours are a result of a child being unable to meet expectations due to lagging skills. These lagging skills must be identified and supported. He suggests that a child may be developmentally delayed in flexibility, adaptability and frustration tolerance, or lack crucial cognitive and emotional skills. For children with ADHD, problems with executive functioning relating to planning, initiating, and carrying out actions can contribute to ODD.

In contrast, Dr William Walsh believes that disruptive behaviour can be caused by certain nutrient deficiencies or overloads, such as excess copper, and can be treated with nutrient therapy.

Current research suggests that symptoms of ODD have been associated with PANDAS – in at least some cases. PANDAS results from the body’s immune system antibodies attacking parts of the brain. This little-known illness results in the sudden onset of mental health issues. PANDAS stands for Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus.

The onset of PANDAS usually follows an ear, nose or throat (ENT) infection from Group A Beta Haemolytic Streptococcus (GABHS). In some cases, GABHS antibodies can damage parts of the brain, resulting in a range of behavioural disorders such as OCD, Oppositional Defiant Disorder, Tourette’s, ADHD and even psychosis.

The prevalence of Post-Traumatic Stress Disorder (PTSD) with ADHD is around 5%, increasing to just over 20% in sexually abused children.

Similarities in the symptoms of ADHD and PTSD can make differential diagnosis challenging and may lead to misdiagnosis.

Symptoms may include:

• Hyperarousal
• Hypervigilance
• Irritability
• Sleep disorders
• Inattention
• Executive dysfunctions

Because of these overlaps, it is essential that during the diagnostic interview a patient’s history is thoroughly reviewed to ensure no traumatic events are overlooked. Misdiagnosis can lead to inadequate treatment, including potentially harmful interventions that address ADHD rather than PTSD.

Rejection sensitivity is part of ADHD, with almost 100% of people with ADHD experiencing it. Many parents find it comforting to know there is a name for this experience.

Rejection Sensitive Dysphoria (RSD) is an extreme emotional sensitivity and emotional pain triggered by the perception of being rejected, teased, or criticised by someone important in your life. For those with RSD, the emotional hurt is felt more intensely than for people without the condition.

Failing to meet your own or others’ high standards and expectations can also trigger RSD.

External responses to RSD can include instantaneous rage towards the person who caused the perceived pain.

Internal responses can resemble mood disorders, with emotions shifting from feeling perfectly fine to intensely sad in a very short time. This can sometimes be mistaken for Borderline Personality Disorder (BPD).

Because RSD can lead people with ADHD to anticipate possible rejection, they may become hyper-vigilant. This is often mistaken for social anxiety — an intense fear of humiliating or embarrassing yourself in public and being harshly judged as a result.

This can manifest in two main ways:

• Becoming afraid to try for fear of failure, leading to underachievement in life
• Becoming perfectionistic, constantly driven to achieve more, avoid criticism, and strive for unattainable perfection

There is a greater presence of ADHD symptomatology in schizophrenia compared to that reported in the general population.

Schizophrenia is a mental health disorder that can interfere with your ability to:

• Make decisions
• Think clearly
• Control your emotions
• Relate to others socially

While some characteristics can appear similar to ADHD, they are two very different disorders. The symptoms of schizophrenia must occur for more than six months and may include:

• Hallucinations — hearing voices, or seeing or smelling things that aren’t real, but seem real to you
• Delusions — false beliefs about everyday situations
• Negative symptoms, such as feeling emotionally dull or disconnected from others, wanting to withdraw socially, or appearing depressed
• Disorganised thinking — trouble with memory or difficulty putting thoughts into words

Possible causes of schizophrenia include:

• Genetics
• Environmental factors
• Brain chemistry
• Substance use

There is a 10% risk of developing schizophrenia if you have a first-degree relative with the disorder, and a 50% chance if you have an identical twin who has it.

Children with ADHD have an increased risk of seizures, with approximately 14% developing seizures.

ADHD is the most common co-occurring disorder in children with epilepsy. Studies suggest that:

• 30–40 out of 100 children with epilepsy have ADHD (compared to 7–9 out of 100 children without ADHD)
• Nearly 20 in 100 adults with epilepsy have ADHD (compared to 2–4 out of 100 adults without ADHD)

Symptoms of ADHD may complicate the diagnosis of epilepsy, as they can be mistaken for seizures.

ADHD and Childhood Absence Epilepsy (CAE) have similarities in symptom presentation. Inattentiveness — a core symptom of ADHD — is also common in children with CAE who experience frequent seizures. CAE symptoms often include periods of staring into space, which may be mistaken for inattentive ADHD.

Differentiating between ADHD and CAE is vital, as misdiagnosis may delay appropriate treatment or lead to unsuitable medication regimens.

If a person is having seizures, treating these first should be the priority. If seizures can be controlled, some symptoms initially thought to be due to ADHD may improve.

Most people develop normal sensory functioning, but around 10% of children develop Sensory Processing Disorder (SPD).

In children who also have ADHD, ASD, are Gifted, or have Fragile X Syndrome, the prevalence of SPD is much higher.

Studies suggest that the sympathetic and parasympathetic nervous systems are not functioning as they should in children with SPD.

Primitive reflexes are evolutionary reflexes important in the early days, months or years of life, supporting a baby’s survival. If these reflexes are retained beyond 12 months, they may indicate a structural weakness or immaturity of the central nervous system (CNS) and may contribute to SPD symptoms.

SPD can impact all areas of life — for example, feeling anxious in or avoiding crowded/noisy places, or having peers avoid a child because they play too roughly or don’t respect personal space.

The causes can be unclear, but risk factors (in addition to those above) include:

• Maternal deprivation
• Premature birth
• Prenatal malnutrition
• Early institutional care
• Repeated ear infections before age 2
• Retained Primitive Reflexes

Symptoms of SPD

Over-sensitivity

• Trouble focusing – can’t filter out distractions
• Dislikes being touched
• Notices sounds/smells others don’t
• Meltdowns, fleeing or becoming upset in noisy crowded places
• Fears for safety even without real danger
• Difficulty with new routines, new places, or change
• Shifts/moves around due to discomfort
• Very sensitive to clothing textures

Under-sensitivity

• Constant need to touch people or things
• Difficulty respecting personal space
• Appears clumsy or uncoordinated
• High tolerance for pain
• Plays roughly and takes physical risks

Research suggests children with ADHD experience extensive sleep disturbances, which not only co-occur but may be intrinsic to ADHD itself.

Because children with sleep disturbances often display behaviours resembling ADHD, it can be challenging to determine which condition is primary and which is secondary. Accurate identification of the specific sleep abnormality is critical, as successful treatment depends on an accurate diagnosis.

Evidence shows that although children with ADHD may have similar total sleep time to their peers, they often experience poorer sleep quality, which worsens ADHD symptoms. Successful management of sleep disturbances can significantly improve daytime functioning. For example, sleep disorders lasting a week or more can lead to emotional issues or cognitive impairment, and have been linked to increased student–teacher conflict and reduced closeness.

Clinicians should consider sleep-disordered breathing, such as Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS). Research indicates that treating OSAHS can relieve ADHD symptoms in 81% of affected children. Effective treatment of snoring alone may improve ADHD symptoms in 25% of children with both conditions, suggesting hypoxia may play a role. The incidence of ADHD is over 30% in OSAHS children and increases with age, making early intervention important.

Stimulant medications used for ADHD can sometimes worsen sleep quality, causing delayed sleep onset, shorter duration, or night awakenings. These effects include longer sleep latency, reduced sleep efficiency, and shorter overall sleep time. Paediatricians should closely monitor sleep and adjust medications if needed.

Good sleep hygiene is essential for everyone, but especially for those with ADHD. Research shows that night-time media use contributes to sleep problems and internalising symptoms in adolescents with ADHD. This includes shorter sleep duration, increased anxiety and depression, greater daytime sleepiness, and more panic and anxiety symptoms.

Recommendations for improved sleep quality include:

• Minimise screen and blue light exposure in the evening
• Wear blue light blocking glasses (red/amber lenses) at night
• Increase natural daylight exposure during the day to help reset circadian rhythms
• Take a warm Epsom salts bath
• Massage
• Use calming essential oils
• Supplement with magnesium
• Practise breathing techniques or meditation
• Ensure a completely dark sleep environment
• Remove electronics from the bedroom
• Use dim red lighting in the evening
• Try binaural beats
• Consider a weighted blanket

Slow processing speed is not a learning or attention disorder in itself, but it can contribute to difficulties in these areas and also affect executive functioning skills.

Processing speed refers to how quickly you take in information, make sense of it, and begin to respond. This information may be visual (letters, numbers) or auditory (spoken language). Children with slow processing speed often take longer than their peers to perform tasks, whether academic or everyday activities. They may struggle to get started on assignments, stay focused, or monitor their progress.

Slow processing speed can impact learning at all stages. For young children, it may make it harder to master the basics of reading, writing, and counting. For older children, it can affect their ability to complete tasks quickly and accurately. It can also impact participation in sports, home routines, and social interactions.

Common difficulties include:

• Finishing tests within the allotted time
• Completing homework in the expected timeframe
• Listening or taking notes while a teacher is speaking
• Reading and taking notes simultaneously
• Solving simple maths problems mentally
• Completing multi-step maths problems in the given time
• Producing detailed, complex written projects
• Keeping up with conversations
• Feeling overwhelmed by too much information at once
• Missing nuances in a conversation
• Following multiple-step instructions
• Needing to re-read information for comprehension
• Taking extra time to make decisions or respond

Slow processing speed is not related to intelligence—it is about the pace at which information can be taken in, processed, and used.

ADHD itself is not a specific learning disability (SLD), but because ADHD impacts concentration and focus, it can make learning significantly more difficult. When a specific learning difficulty is present alongside ADHD, a child’s challenges are compounded further.

Children with ADHD are 40% more likely to have a specific learning disability than children without ADHD. Common SLDs in children with ADHD include difficulties with language, reading, writing, and maths.

It is essential that SLDs are diagnosed in addition to ADHD so they can be supported appropriately. A child whose achievements are below what would be expected for their age, intelligence, and prior schooling requires specific, individually administered, standardised testing to identify potential learning problems.

Professionals assessing for ADHD should also screen for SLD, and vice versa. Children with SLD should be assessed for other conditions such as auditory processing disorders, motor disorders, and speech & language difficulties.

It is important to distinguish between difficulties caused by ADHD and those resulting from SLD to ensure the correct interventions are provided.

Children with speech and language disorders often have difficulty processing information and/or expressing themselves. Children with ADHD can experience similar problems, making it challenging to determine whether the main issue is an attention difficulty or a language disorder.

Because ADHD can involve hyperactivity, distractibility, impulsivity, and inattention, language and communication can be affected in various ways. This may include interrupting others, struggling to find the right words, speaking too loudly or out of turn, failing to filter out background noise, losing track of conversations, or taking things out of context.

Speech is how we form the words we say and involves four elements:

• Articulation – making sounds
• Phonology – how the sounds of language are put together to make words
• Voice – the pitch, volume, and quality of speech
• Fluency – the flow of speech

Language is how we use words to communicate and understand others. It involves vocabulary (knowing and finding the right words), grammar (the rules for combining words into sentences), and pragmatics (the social use of language, such as reading facial expressions, body language, and tone of voice).

There are three main types of language disorders:

• Receptive language issues – difficulty understanding what others are saying
• Expressive language issues – difficulty expressing thoughts and ideas
• Mixed receptive-expressive language issues – difficulty both understanding and using spoken language

If your child has ADHD, it’s common for them to also struggle with some aspect of speech or language. Consulting their teacher and seeking support from a qualified speech pathologist can help identify strategies to improve communication skills and overall learning outcomes.

ADHD can often impact social skills. Children with ADHD may have fewer friends, be less accepted by peers, and face greater risk of social rejection during their teenage years – even if ADHD symptoms improve over time.

This can occur for several reasons, as children with ADHD may:

• Miss social cues
• Not notice how their behaviour affects others
• Interrupt others
• Misinterpret what others are saying
• Be distracted by unrelated thoughts
• Have difficulty filtering what others are saying
• Lose the thread of a conversation easily
• Struggle to take turns or wait for things
• Have difficulty with self-control
• Be more intense or demanding
• Have trouble planning and following through
• Be more aggressive or lash out physically
• Have meltdowns or display behaviour not typical for their age group

This is not true for all children with ADHD – many have strong friendships, no language difficulties, and can be extremely charismatic. They may also find it easier to connect with slightly older or younger peers, as their emotional age can be a couple of years behind their chronological age.

50% of adolescents with Substance Use Disorder (SUD) also have ADHD.

The substances most commonly used include cannabis, alcohol, cocaine and nicotine, though stimulants are also frequently misused.

This overlap is thought to be linked to impulsivity, self-medication, and addictive tendencies – all of which are more common in ADHD due to the dopamine-boosting effects of many substances. Other contributing psychosocial factors can include academic failure, social difficulties, and permissive parenting styles.

Statistics show that as many as 50% of children with ADHD may also have Tourette Syndrome (TS) or a tic disorder.

Tourette Syndrome is a neurological disorder characterised by involuntary, irresistible, rapid, repetitive muscle movements and vocalisations called “tics”, which can often be accompanied by behavioural difficulties.

Although tics are described as “involuntary”, most people with TS can exert some control over them – but only for a short time. Suppressing tics often leads to a later, more intense outburst. Tics are typically experienced as a build-up of tension that must eventually be released. They tend to worsen with stress and improve with relaxation or intense focus.

TS symptoms are sometimes mistaken for behavioural problems or “nervous habits”, but they are neurological in origin. Tics fall into two main categories:

Simple Tics

• Motor: Eye blinking, head jerking, shoulder shrugging, facial grimacing, nose twitching
• Vocal: Throat clearing, barking noises, squealing, grunting, gulping, sniffing, tongue clicking

Complex Tics

• Motor: Jumping, touching others or objects, twirling, repetitive movements of the torso or limbs, pulling at clothing, self-injurious actions such as hitting or biting oneself
• Vocal: Uttering words or phrases, coprolalia (involuntary swearing), echolalia (repeating sounds or words just heard), palilalia (repeating one’s own words)

People with TS may have a mix of these symptoms, which can vary in intensity from day to day. Mild cases may involve a few facial or shoulder tics, while severe cases can affect multiple areas of the body.

If a child has both tics and ADHD, ADHD medication may worsen tics in more than 50% of cases. Tics can also be a side effect of ADHD medications such as methylphenidate (Ritalin), though they often resolve when the medication is adjusted or discontinued.

PANDAS (Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus) is linked in some cases to Tourette’s and OCD. It results from antibodies produced by the immune system attacking parts of the brain after an infection with Group A Beta Haemolytic Streptococcus (GABHS). This can trigger a sudden onset of behavioural disorders such as OCD, ODD, Tourette’s, ADHD, and even psychosis.

Research has found a link between ADHD and Written Language Disorder (WLD). It was found that girls with ADHD are at higher risk of WLD and reading disabilities than boys.

It is a condition that can cause poor handwriting and for children to become developmentally behind their peers in reading, spelling or writing skills but does not affect overall intelligence.

• ADHD & Co-Morbid Conditions [http://clinical-psychiatry.imedpub.com/adhd-and-comorbid-disorders-inchildhoodpsychiatric-problems-medicalproblems-learning-disordersand-developmental-coordinationdisorder.php?aid=7487#16]

• Writing & ADHD [https://onlinelibrary.wiley.com/doi/pdf/10.1111/ldrp.12099]

• DCD & ADHD [https://www.ncbi.nlm.nih.gov/pubmed/26168770]

• WLD & ADHD [http://pediatrics.aappublications.org/content/128/3/e605.full?sid=b25d59f3-bec8-4e5f-9235-65d454101f9e]

• Learning Difficulties & ADHD [https://www.ncbi.nlm.nih.gov/pubmed/26098006]

• Dysgraphia & ADHD [https://www.ncbi.nlm.nih.gov/pubmed/28741400]

• Microbiome & ADHD [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5581161/]

• Bowel Problems & ADHD [https://www.webmd.com/add-adhd/childhood-adhd/news/20131021/kids-with-adhd-often-prone-to-bowel-problems-study#2]

• Enuresis & ADHD [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2794242/]

• ADHD & Bipolar [https://www.ncbi.nlm.nih.gov/pubmed/25051093]

• Video Games & ADHD [https://www.ncbi.nlm.nih.gov/pubmed/18206354]

• Sleep Disorders & ADHD [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218783/]

• Sleep Apnea & ADHD [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5662391/]

• Sleep Phenotypes & ADHD [https://www.ncbi.nlm.nih.gov/pubmed/30377038]

• Circadian Clock Genes & ADHD [https://www.ncbi.nlm.nih.gov/pubmed/30234417]

• Nighttime Media Use & ADHD [https://www.ncbi.nlm.nih.gov/pubmed/30223187]

• Sleep Problems/Teacher Relationship [https://www.ncbi.nlm.nih.gov/pubmed/29783160]

• Poor Sleep & ADHD [https://www.ncbi.nlm.nih.gov/pubmed/29072500]

• Light Exposure & Sleep [https://www.ncbi.nlm.nih.gov/pubmed/29463186]

• Blue Light & Insomnia [https://www.ncbi.nlm.nih.gov/pubmed/29101797]

• ADHD Medication & Sleep [https://www.ncbi.nlm.nih.gov/pubmed/26598454]

• Sleep Disorders & ADHD [https://www.ncbi.nlm.nih.gov/pubmed/24511653]