ADHD rarely exists in isolation. The prevalence of coexisting conditions such as anxiety, depression, substance use disorders (SUD), and autism spectrum disorder (ASD) complicates both diagnosis and treatment, particularly in telehealth settings.
For virtual healthcare providers, understanding the intricate relationship between ADHD and its comorbidities is essential for delivering effective, patient-centered care at a distance.
We explore the challenges and strategies for managing ADHD and its comorbidities virtually to enhance diagnostic accuracy and treatment outcomes.
Prevalence and impact of common ADHD comorbidities
Over half of adults with ADHD have at least one comorbid psychiatric condition, and nearly 40% have two or more. These comorbidities influence symptom presentation, treatment response, and long-term patient outcomes.
Anxiety disorders
Research has shown that anxiety disorders are prevalent among those with ADHD, with rates ranging from 25% to 50%.
Anxiety can exacerbate ADHD-related executive dysfunction and inattention, making it harder to distinguish primary ADHD symptoms.
Depressive disorders
Comorbidity studies vary widely, but 20 to 30% of people with ADHD will also have Major Depression.
ADHD and depression share overlapping symptoms, including motivation deficits and concentration difficulties.
Inattention in ADHD may be mistaken for psychomotor slowing in depression, emphasizing the need for symptom tracking over periods of time.
Autism spectrum disorder (ASD)
42% of children with ASD also meet ADHD diagnostic criteria.
ADHD and ASD share symptoms such as executive dysfunction and social difficulties but require different treatment approaches. Deficits in social reciprocity (common in ASD) may be harder to assess in a virtual setting, leading to missed ASD diagnoses in ADHD patients – especially in girls and women who mask.
Learn more about the differential diagnosis of ADHD and ASD with our latest webinar.
Substance use disorders
The impulsivity associated with ADHD elevates the risk and severity of substance misuse – research reports that at least 40% of adults with SUD have ADHD.
There are higher rates in untreated individuals as well as higher likelihood of poly drug abuse, suicidal behaviors, a higher rate of relapse, more hospitalizations, and lower treatment adherence.
Challenges of diagnosing and managing ADHD and comorbidities virtually
While telehealth expands access to ADHD care, diagnosing the condition and its comorbidities virtually presents unique difficulties.
Limited nonverbal communication
Virtual consultations may impede the observation of essential nonverbal cues, critical for diagnosing conditions like anxiety and ASD, for example fidgeting or subtle social disengagement. They could be missed or misinterpreted as something else.
“Every person emits hundreds of these small, non-verbal communications every hour. And all of us, including physicians, unconsciously interpret these communications, usually accurately.
Telehealth interferes with those subtle cues, which may result in a patient’s misdiagnosis or inappropriate treatment decisions,” said Walt Karniski for Additude.
Reliance on self-reported data
Without in-person evaluations, you must rely on patient self-reports and patient narratives, which are subjective and open to interpretation.
Environmental variability
A patient’s behavior during a virtual appointment may not be fully representative of their daily functioning.
A highly structured home setting may mask executive dysfunction, whereas external distractions in a clinic environment might reveal more impairments and be more demonstrative of their experiences.
Symptom overlaps
Many conditions may overlap and result in misdiagnosis – or be totally missed altogether.
For example, inattention in ADHD can mimic depression or anxiety, emotional dysregulation in ADHD can mimic mood swings in bipolar disorder, and social withdrawal in anxiety may be mistaken for ASD-related social interactions.
Treatment response and complexity
Patients with multiple comorbidities often require more nuanced, individualized care plans. For example:
- Stimulant medications may exacerbate anxiety symptoms
- Stimulants can improve ADHD symptoms but may worsen behaviors associated with co-existing conditions
- SSRIs or SNRIs, used for anxiety and depression, may not address ADHD symptoms effectively
- Comorbid conditions can reduce the effectiveness of ADHD treatments
- People with ADHD often take medications for other conditions, which can lead to drug-drug interaction
Strategies for effective virtual ADHD care
To mitigate these challenges, virtual providers should consider the following strategies.
Comprehensive screening to assess for comorbidities during initial evaluations
Gathering as much information as possible about your patient before their virtual appointment can help you get a full understanding of their experience. Validated tools that can help identify coexisting conditions during screening include:
- ASRS (Adult ADHD Self-Report Scale)
- GAD-7 (Generalized Anxiety Disorder-7)
- PHQ-9 (Patient Health Questionnaire) for depression
- AUDIT-C (Alcohol Use Disorders Identification Test)
- SCQ (Social Communication Questionnaire) or SRS (Social Responsiveness Scale) for autism traits
Structured diagnostic tools and objective testing
Subjective measures are important to gather a holistic view of your patient. However, they must be supplemented with objective ADHD testing tools like QbCheck for accurate diagnoses.
Objective measures quantify attention, impulsivity, and hyperactivity using digital technology. You get data-driven insights which standardize your evaluation pathway, ensuring clinical decisions are accurate in virtual settings.
Our medical technology is the first and only to be recommended by the National Institute of Clinical Excellence when evaluating ADHD and reveals treatment efficacy more accurately than a rating scale.
According to research, our medical technology captures 86% of patient’s treatment effects compared with only 37% of patient’s improvement captured by the ASRS rating scale.
With direct retest reports, you can see the direct impact of treatment on patient symptoms and if it should be adjusted accordingly.
Multidisciplinary collaboration
Research in child, young adult, and adult ADHD have shown that best outcomes come from an integrated, multimodal treatment approach.
For patients with complex comorbidities, virtual providers should coordinate care with psychiatrists for medication management, psychologists for cognitive behavioral therapy, and occupational therapists for executive function support.
ADHD and its comorbidities evolve over time. You should schedule consistent follow-ups to track symptom progression and establish:
- Routine follow-ups (every 3-6 months) to track symptom progression
- Digital symptom tracking tools like QbCheck to easily compare retest reports
- Flexible treatment adjustments based on objective data and patient feedback
Improve patient outcomes with QbCheck
We assessed the performance of remote testing with 6,159 patients. It was found that:
- 95% all patients reported that the instructions were easy to follow
- 94% of patients had an appropriate home test-environment.