ADHD Comorbidity The challenge of dealing with Attention Deficit Hyperactivity Disorder (ADHD) is increased exponentially by the individual having accompanying challenges. These challenges may be psychological as well as social. A primary concern for parents, patients, and researchers is that there are a large number of individuals with the original condition who remain undiagnosed or misdiagnosed. This means that the accompanying condition also remains undiagnosed. It therefore becomes critical that there is an increase in screening for ADHD and the accompanying comorbidities.

ADHD

It is believed that ADHD affects between 3-6% of American children who are around school age (MIrsky 2001). Historically boys have been the primary targets for ADHD, but it should be noted that a significant number of girls are also afflicted with the condition. In samples of individuals taken from clinics the ratio of males to females is 10:1(Goldman, Genel, Bezman and Slanetz 1998). This ratio however does not present an accurate picture of the problem as other studies that have employed samples drawn from community-based populations have a ratio of 3:1. It is suggested that the higher clinical rate for boys captures the social experience that boys are more likely to be sent for evaluation because of behaviour and other associated problems within the school system. Boys and girls with ADHD demonstrate similar levels of symptomatic behavior such as "inattention, impulsivity, hyperactivity and comorbidity" (). Boys unlike girls have twice the rates for behaviors related to defying authority.

It is estimated that approximately 66% of the children in the United States who test positively for ADHD may have an additional disorder (Arcelus & Vostanis 2005). The disorder may take the form of a mental health disorder or it may be a "neuro-developmental" challenge. The existence of comorbidity confounds the diagnosis of ADHD. A national study which examined in excess of 60,000 children, who were between the ages of 6-17 years; identified psychiatric and physical comorbidities as prevalent in children with ADHD (Larson 2011). The study determined that around 67% of children with ADHD also had some other disorder. This clearly indicates that this is a serious problem and requires immediate attention. The complexity of the issues often prevents adequate diagnosis and investigation of the phenomenon.

The issue that confronts doctors and researchers is that the major symptoms that are used to diagnose ADHD such as "inattention, impulsivity and hyperactivity" are also symptoms for other mental health disorders. The overlapping of symptoms presents the problem of determining which of the conditions comes first. It therefore becomes necessary to determine the true underlying condition as distinct from the companion condition or comorbidities. It is also important to demonstrate that ADHD is not itself a symptom of a wider problem (Farone & Kunwar 2007).

This effectively highlights the effects of comorbidity. Comorbidity is a problem because it significantly influences the presentation of the case. It affects proper diagnosis by masking the actual problem through a series of companion problems. Additionally comorbidity greatly increases the actual material problems patients experience with the condition. The burden of care and living is increased in a manner that could easily discourage the caregiver and the patient. It therefore becomes necessary to where possible eliminate comorbidity. Determining comorbidity is difficult when both of the medical conditions are chronic. If a child has bipolar disorder along with ADHD, the presence of the bipolar disorder adversely complicates the diagnosis of ADHD. This complication places children at a greater risk for developing additional psychiatric disorders. As well as it prevents treatment of the second disorder that is masked by the primary problem.

What is comorbidity?

There are multiplicities of definitions relating to comorbidity. Since 1970 one dominant definition has been that of comorbidity being a "distinct additional entity that has existed or may occur during the clinical course of the patient who has the index disease" (Feinisten 1970). The definition was given greater expansion by Blashfield, Keeley & Burgers (2009) who focused on the presence of different diseases in the same individual. The focus of Blashfield, Keeley & Burgers appears to the mere presence of a separate disease in one and the same person. However comorbidity is conceived it is clear that the major issue is that a single individual presents with at least two diseases at the same time. The interaction between the diseases is often unclear. It is often difficult to determine which of the two conditions can be considered to be primary and secondary.

Some researchers contend however that comorbidity is more a failure of diagnosis...

This is particularly so in younger children who are often unable to adequately disclose the symptoms they are experiencing. This means that what may appear as another condition might actually be the same condition being expressed differently in the same individual. The second manifestation of the problem is inadequately diagnosed by the clinician because of the differential experience of the patient. In younger children their immature development of the cognitive facets may produce the effect described.
The situation is further complicated by the fact that ADHD and the disorders that it is often combined with are linked to both environmental and genetic factors. This reality has caused some theorists to suggest that there should also be different types of ADHD based on their interaction with comorbid factors (Barkley 2006). This clearly suggests that comorbidity is not easy to assess, and describe where the symptoms are visibly and chemically highly homogenous in their manifestation.

When examining comorbidity it is possible to divide the comorbidity into two categories those who engage in disruptive behaviors that become manifest through externalization, and those who internalize. Disorders that are classified as externalizing have higher rates of comorbidity with ADHD than disorders described as internalizing. Wilens (2002) suggests that the rates of comorbidity for externalizing behaviors could be as high as 90%, while the rates for internalizing behaviors is only at 50%. This difference remains even when the sex of the individual is held constant. A cross-sectional study, that examined children identified the most frequent comorbidity as oppositional defiant disorder (ODD), the next most frequent was mood disorder Taurin (2010). Anxiety and dyslexia were also part of the spectrum of behaviors found simultaneously with ADHD.

The concern for the differential rates of diagnosis for externalizing and internalizing comorbidity is, whether the observed rates are driven by structural forces or are a valid measure of the existing state of the phenomenon. Externalizing behaviors are very similar in nature and manifestation to ADHD so it is probable that the overlap between the disorders provides difficulty in providing a valid measurement of the problem and inflates the connection between the two categories of individuals.

Adults also demonstrate comorbidity. In the adult population the comorbidity includes many of the children's challenges as well as some self-destructive behaviors. The adult populations showed higher incidences of substance abuse. The comorbidity for substance abuse disorders in adults was approximately 45% (Jacob et al. 2007). This finding is important because of the implications for clinical practice and many other social concerns. It may be useful to examine the converse position where drug abusers are examined for ADHD. The issue of comorbidity in both children and adults becomes important at the diagnostic level. At the diagnostic level there is a need to ensure that when diagnosis ADHD clinicians also look for accompanying issues because of the high prevalence of those issues.

Common disorders that demonstrate comorbidity

Having discussed the issue of comorbidity it is important to describe some of the more common psychological and other conditions that may present along with ADHD. One of the main comorbid disorders with ADHD is depression. It is difficult to parse the difference between an emotional outcome of ADHD and depression as comorbidity (for the reasons stated earlier). Spencer et. Al. (1999) suggests that it is possible that as many as 40% of the children and adults who have ADHD are also depressed. The symptoms of depression are often observed many years after the individual has been diagnosed as having ADHD.

It is possible that depression may be a response by the individual to external stimuli for which they may have no control. The presence of ADHD may produce unpalatable responses in the peers of the individual. They persons with ADHD may experience rejection or bullying and name calling as a consequence. As their school experiences become more negative, school becomes a difficult environment for the individual. In cases like these it may be necessary to not only address the ADHD but also the need for strategies to relate to the treatment from other individuals. It is also possible that depression may have a genetic link as it may run in the family. Persons who have other persons in their family with depression are more likely to be depressed themselves. Whether the link is genetic or environmental the outcome is significantly increased hardship for the persons suffering with ADHD (Amiri, et al. 2013).

As a further extension of depression, children may become suicidal. The outcomes for boys and girls are different. In that boys tend to…