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Sunday, March 1, 2015
What Is ADHD and ODD?
I have 3 boys who all have autism. My oldest has been diagnosed with Pddnos and ADHD. We have tried 2 different kinds of medications in the past but neither seemed to do any good. It seemed that the medications only made him worse and even more aggressive. Now we are wondering if he has been misdiagnosed with ADHD, and should have been diagnosed with ODD instead. Not real sure what to think as I am fairly new to all of this and don`t know much about any disorder other than what I am finding on the internet. Thanks very much.
Your son's story is fairly common among children with autism spectrum disorders (ASDs). Of course, it is not possible to tell from a brief electronic mail, but he probably was not misdiagnosed.
The usual medicines for managing ADHD symptoms are the psychostimulants, such as methylphenidate (Ritalin, Concerta), amphetamine (Adderall), and dextroamphetamine (Dexedrine). A newcomer to the ADHD medicines is atomoxetine (Strattera), which is not really related to the psychostimulants.
In general, the psychostimulants are remarkably safe and highly effective in most typically-developing children with ADHD. For reasons that we do not understand, children with ASDs seem to have a much more variable response to psychostimulants than typically-developing children. First, many children with ASDs do not show the dramatic reductions in activity level, enhanced attention, and lessened impulsivity that we normally expect with these medicines. Second, the rates of side effects, such as irritability, sleep problems, stereotypic behavior, tearfulness, self injury, and/or tics seem to be to be higher for children with ASDs. The increased aggression that you saw with your son would be consistent with this.
Even though children with ASDs have more variable responses to the psychostimulants, it still makes sense to try these medicines first when a child has symptoms of ADHD. That is because we know a lot about these medicines (they have a good safety track record) and some children with ASDs do respond well to them. However, everyone involved in the child's care needs to be prepared to "back off" when a child with ASD does not appear to benefit. (Not all doctors know about the variability of response and higher-than-usual rate of side effects with the psychostimulants. Some respond to a lack of response with increased doses, on the assumption that the child's dose is too low. That, of course, can lead to additional problems.)
If a child with an ASD and ADHD symptoms does not respond to a moderate dose of psychostimulants or shows the side effects described above, then the doctor may decide to try atomoxetine, another ADHD medicine. Some children have a poor response to one type of psychostimulant, yet react favorably to another. Some children may require treatment from a completely different class of medicine, such as the older antidepressants. But these have their own liabilities and should be introduced only by clinicians experienced in their use. There are other medicines that may be used as well.
Michael G Aman, PhD
Professor of Psychology and Psychiatry
College of Medicine
The Ohio State University