Kids With Multiple Diagnoses

When you have a child diagnosed with a mental health or learning disorder, it’s not unusual to find out that they also meet the criteria for another diagnosis. Your teen with ADHD might also have anxiety. Your first grader with autism might also have ADHD.

Sometimes multiple diagnoses — also known as “co-occurring” or “comorbid” disorders — are made at the same time. A child who is struggling might be evaluated and diagnosed with anxiety and depression, for example. But often a child is first diagnosed with one thing and another diagnosis is added later.

“Families can feel overwhelmed hearing that their child has multiple diagnoses,” notes Megan Ice, PhD, a clinical psychologist at the Child Mind Institute. “There can be the perception that the more diagnoses, the sicker the child is.”

But that’s not necessarily the case. When a child has multiple diagnoses, it means they have symptoms that can’t all be attributed to or treated by one diagnosis. “By identifying multiple diagnoses, we’re able to open up paths for the treatments that will be effective for more of the symptoms,” Dr. Ice explains.

In one widely cited study of 10,000 adolescents, 40 percent of those who had one mental health disorder met the criteria for another. But there are a variety of reasons why mental health and learning disorders so often occur together.

Some disorders are linked to the same brain systems. “If you’re diagnosed with one anxiety disorder, like selective mutism, the likelihood is high that you’re going to have another anxiety disorder, like specific phobia, generalized anxiety disorder, or social anxiety,” says Paul Mitrani, MD, PhD, a child and adolescent psychiatrist at the Child Mind Institute. “It makes sense because it’s the same brain system that’s affected, just presenting in several different ways. So that that’s very common.”

Several different disorders can be linked to the same neurotransmitters — chemicals like dopamine and serotonin that are used to send messages in the brain. For instance, the serotonin system is involved in both anxiety and depression. “When the pathways related to serotonin in the brain are not working as well,” says Dr. Mitrani, “you’re at a higher risk for anxiety, as well as depression and OCD.”

But it’s also common for a child’s struggles with one disorder to lead to another. For instance, a child with ADHD whose impulsivity leads to a lot of conflict with their parents can develop a behavior disorder. Kids with autism might develop anxiety because the world feels unpredictable and overwhelming. Or children with learning disorders who are struggling in school may develop anxiety or depression.

“It can be really hard to have ADHD or autism, or to struggle with learning, so it makes sense that you might have difficulty regulating your emotions and behavior or that you might develop anxiety or depression,” notes Dr. Ice.

Sometimes, children with several diagnoses have been seen, over the years, by different clinicians, who may have evaluated them differently and added a diagnosis without withdrawing an earlier one.

“The more interactions somebody has with the mental health system, the increased likelihood that they’ll have multiple diagnoses because of different providers seeing and hearing different things at different times,” notes Dr. Ice. A child can end up with a list of diagnoses that they’ve had in the past, but they don’t meet the criteria for anymore, she adds.

A study of adolescents with co-occurring disorders found that slightly more than half (61 percent) had two disorders from one larger class of disorders, such as mood, anxiety, attention, or behavior disorders. Another quarter (25 percent) had disorders from two different classes, and 11 percent were affected by three different classes of disorders.

Some of the common combinations include:

• ADHD + Anxiety: Difficulty focusing, restlessness, and irritability can appear in both disorders, which can result in misdiagnosis — but many children also have both. Academic struggles, social difficulties, and consistent negative feedback can cause chronic stress, leading to anxiety over time.
• ADHD + Oppositional Defiant Disorder (ODD): Kids with ADHD may be easily frustrated and have difficulty complying or following instructions from parents and other adults, which can lead to oppositional or defiant behavior.
• ADHD + Depression: As the academic and social impact of ADHD builds up over time, kids can develop low self-esteem and depression.
• Anxiety + Depression: It’s very common for kids who experience chronic worries to develop sadness, a loss of interest in things they enjoy, and other symptoms of depression.
• Autism + ADHD: A study of more than 4,000 children with autism found that 40 percent also had ADHD. Sometimes ADHD symptoms are recognized first, and autism is diagnosed later — or vice versa. Autism and ADHD both run in families and have genetic factors in common.
• Anxiety + OCD: OCD is an anxiety disorder, but it can appear with other anxiety types, like generalized anxiety or social anxiety.Kids may struggle with intense fears and compulsive rituals as well as general worry or panic.
• Trauma-Related Disorders + ADHD, Anxiety, Depression, or ODD: Trauma can impact a child’s mood, behavior, attention, and emotional regulation, leading to symptoms in all those areas. A trauma-informed approach is essential for accurate diagnosis and effective treatment. Trauma-informed assessments can help identify the root cause of symptoms.
• Learning Disorders + Anxiety or Depression: Children who have an extra hard time with learning often struggle with frustration and low self-esteem, which can cause them to develop anxiety or depression.
• Tic disorders + ADHD or OCD: More than three-quarters of children with Tourette’s disorder have at least one other disorder, with ADHD and anxiety being the most common.

When a child has more than one disorder, how do you decide what to treat first? Whichever one seems primary, says Dr. Ice. “What is the thing that’s actually leading to the most problems? What is interfering with the child’s functioning the most — we want to figure out a plan for treating that first.”

If a child with ADHD is not paying attention in class, is hyperactive, and is getting into a lot of trouble, these difficulties could result in anxiety. “So, you treat the ADHD first, then you reassess to see if the anxiety gets better,” says Dr. Mitrani. “If it gets better, then you probably don’t need to use a medication or intervene for the anxiety. But if it doesn’t get better? Then we need to figure out how to treat the anxiety.”

Sometimes you can work on more than one disorder at the same time. A child with a learning disorder who becomes depressed should get support for their learning issues as well as treatment for depression.

But if you’re starting treatment with medication, Dr. Mitrani stresses, medicines should always be introduced one at a time. “You don’t start with two medicines at the same time because if something gets better or worse, you won’t know what the cause is,” he explains. For instance, for a child who has ADHD and anxiety, “if you start a stimulant and antidepressant at the same time and all of a sudden the child’s not sleeping, what’s causing that?”

When treatment involves medication, the prescribing doctor needs to consider how medication for one might exacerbate or affect symptoms for another. For instance, stimulant medication for ADHD can worsen anxiety. “If a child has both, we may start with treatment for ADHD, but if the stimulant makes the anxiety worse, then we have to reassess and think about other options,” says Dr. Mitrani.

Medications for one disorder can also affect how another medication for a co-occuring disorder is metabolized — limiting its effectiveness or increasing the side effects. “Anytime you combine medications, you want to make sure there are no interactions that can worsen or compound side effects,” says Dr. Mitrani.

One of the risks when children have several mental health disorders is that they will be prescribed multiple medications without clarity on what each is intended to do and whether it is working. “The risk is that in layering medicine on medicine, you lose track of the underlying problems, and how well each medication is being tolerated,” said Dr. Mitrani.

“You can use any of these medicines in combination,” he notes, “but they need to be combined carefully to get an accurate picture of their effectiveness and manage side effects, especially when you’re dealing with meds that have more concerning side effects, like antipsychotics.”

One disorder could also make it more difficult for a child to participate successfully in therapy for another disorder. For instance, if a child has social anxiety and depression, the social anxiety could interfere with their ability to engage in therapy for depression that includes participation in a group, such as DBT (dialectical behavior therapy). If a child has ADHD and anxiety, the ADHD can interfere with their ability to follow through with a step-by-step treatment for anxiety like exposure and response prevention (ERP).

Kids with several mental health challenges may require more tailored treatment. “This involves adapting typical treatment for one of the diagnoses to include what is beneficial for the other diagnosis as well,” says Dr. Ice. For instance, the standard cognitive behavior therapy treatment for anxiety, Coping Cat, has been customized for autistic kids with anxiety, resulting in a treatment called BIACA (Behavioral Interventions for Anxiety in Children with Autism).

Dr. Mitrani stresses the importance of making sure to educate parents on all their options. “What’s possible with medicine? What’s possible with therapy? Where is parent work important? Where is working with the schools important? Since medications can come with concerning side effects, we want to make sure we’re setting specific goals for treatment interventions, carefully monitoring those interventions for effectiveness, and adjust things or bring in other approaches as needed.”