ADHD comorbidity in children: diagnosis challenges and prevalence

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.

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 be more successful at attempts at suicide and girls less successful. One of the important interventions that will reduce this risk is early stimulant treatment (Karlstad, O. Furu, Skurtveit, & Selmer, 2014).

Another major comorbidity is bipolar disorder (BD) (Halldorsdottir, & Ollendick, 2013). This particular comorbidity tends to be observed at higher rates in boys. Children with BD may demonstrate behaviors that are very similar to ADHD. The symptoms are often difficult for the children to manage effectively. Additionally, their social interactions suffer greatly as they may misunderstand the meaning of specific social interactions. Children may infer negative motives to the actions of their peers, when an objective assessment would suggest that this is not the situation. This may result in temper tantrums that are often very length and destructive.

The final comorbidity that will be discussed is anxiety. While anxiety is a response to stress that is "normal." In persons with ADHD it may disturb the normal routine of the individual. General anxiety is thought to exist in a significant percentage of the children with ADHD. The problem is however that when anxiety is present the children may have a reduction in impulsivity so that their ADHD goes undiagnosed. Anxiety acts as a confounding factor. One explanation for the anxiety in children with ADHD is that the children struggle with accomplishing routine tasks on a daily basis. Behavior therapy has been shown to be useful in relieving the symptoms of anxiety.

Living with ADHD is a difficult prospect; it is however complicated and made more arduous by the presence of other disorders. Thus comorbidity becomes a central feature of any treatment program for ADHD. It is critical that clinicians actively assess children for accompanying disorders. Whether the source is genetic or environmental the treatment protocols employed will make life more palatable for the individual.