People living with a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) face significant obstacles every day of their lives in achieving their most relevant personal goals.
And not only because of the impact of alterations in executive functions, such as attention and / or behavioral inhibition, but also because of the “social frictions” in which their particular clinical expression is involved. And it is that from an early age, they can be qualified as agitated or even violent, which conditions the way in which they live this period of age.
The literature on ADHD suggests that beyond the limits imposed by this neurodevelopmental disorder, the emotional consequences related to difficulties in achieving educational goals or meeting all the demands of a job also contribute.
In this article we will discuss some of the comorbidities of ADHD. All are important because they are linked to a worsening of symptoms and / or their prognosis and evolution. Let us examine such an important question without further ado.
Attention deficit hyperactivity disorder
ADHD is a neurodevelopmental disorder associated with three different symptoms.Namely: impulsivity (problems of inhibiting impulses or delaying incentives), inattention (difficulty in maintaining “focus” for the time necessary on a task in progress) and motor hyperactivity (feeling of lack and inability to maintain – is in a state of immobility in the contexts in which it should be done). There are different profiles of ADHD because each person who has it has very different symptoms (emphasis on inattention or hyperactivity, or even a mixture of the two).
It is estimated that between 3% and 10% of the child population has symptoms consistent with this diagnosis according to the DSM-5 manual, with an expression that very often begins before the age of five and begins exceptionally after seven years. The resonances on cognition, in particular in the executive function (inhibitory planning or control), imply notorious consequences on various domains of the daily functioning. Therefore, many of them have been used to explain the comorbidities that the literature has detected for this same group of patients.
Comorbidity is the presence of two or more clinical entities (including ADHD) simultaneously in a single individual. (Child or adult), so as to establish a synergistic relationship between them. The result cannot be calculated through a simple sum of the diagnoses, but an interaction between them takes place from which a unique manifestation emerges for each of the people who can present it. And this is so because these comorbid disorders intertwine with the dimensions of personality and character, resulting in this process of deep psychopathological idiosyncrasy.
In patients with ADHD, comorbidity is the rule, not an exception, therefore the presence of all the disorders that will be detailed at the start of the therapeutic relationship must be taken into account (Initial interview with parents and child, definition of evaluation strategies, etc.). It is also known that co-morbidity can overshadow the prognosis and exacerbate the barriers the family will face over time, as up to 50% of cases extend beyond adolescence.
Comorbidities of Attention Deficit Hyperactivity Disorder
We detail the six disorders that most often coincide with ADHD. If initially the emphasis was on externalizing disorders (disruptive behaviors), we are now also beginning to consider the importance of internalizers (major depression, for example) for the balanced development of the person with this condition. clinical picture.
1. Major depression
Depression is a disorder characterized by deep sadness and great difficulty in experiencing pleasure. In the case of children, as well as adolescents, it is sometimes expressed as irritability (and is confused with behavioral disturbances). The scientific community is increasingly aware of the possibility that such an emotional problem arises in people diagnosed with ADHD, very often as the emotional result of existing limitations in adjusting to school or in forming relationships with them. of equals.
In all cases, it is estimated that between 6% and 9% of children and adolescents with ADHD have a co-morbid diagnosis of depressionThis increases their subjective level of stress and exacerbates the underlying cognitive problem. These are images that start much earlier than those observed in the general population, and that require the design of more intense and longer interventions. The high participation rate of both definitely prompted the research community to define common aspects that could explain and predict it.
After several studies on this subject, it was concluded that the common axis was emotional deregulation; understood as the presence of disproportionate affective reactions to the detonating event, the great lability of internal states and the excessive emphasis on past negative experiences or worrying expectations for the future. Of all the features associated with such a relevant shared factor, frustration intolerance rises like this with greater explanatory and predictive power.
It has been described that up to 72% of children with ADHD have this trait, which results in significant difficulty in delaying reward or tolerating the existence of obstacles that prevent their immediate and unconditional achievement. This circumstance would precipitate the emergence of a recurring sense of failure, the dissolution of any motivation to achieve the goals and the firm belief that one is different and / or inappropriate. All this can be accentuated when, in addition, we coexist every day with constant criticism.
2. Anxiety disorders
Anxiety disorders are also very common in ADHD. Studies on such a question conclude that between 28% and 33% of people with this diagnosis meet the criteria for an anxiety problem, And especially when they reach adolescence. It is also at this stage that they begin to notice differences between boys and girls in terms of the risk of suffering from it, being much more common in them than in them. Compared to subjects with and without ADHD, we note that in the first case, these disorders appear at an early age and are more persistent.
Boys and girls with ADHD have higher levels of social anxiety than those without, And are more likely to report acute panic attacks and specific phobias. The latter can be formed by normal evolutionary fears which persist despite the passage of time, which accentuate them and accumulate them with those which arise in later periods. There are also studies describing a higher prevalence of generalized anxiety disorder in this population, characterized by constant / unavoidable concerns around a broad constellation of daily activities.
If you know this comorbidity is more common in people with mixed ADHDIn other words, with symptoms of hyperactivity / inattention. However, attention deficits are believed to be related to anxiety in a more intimate way than any of its other forms of expression. Despite this, anxiety accentuates to the same extent impulsiveness and alterations in executive function, aggravating any difficulty (academic, professional, etc.) that one might go through.
3. Bipolar disorder
Childhood bipolar disorder and ADHD significantly overlap clinically, so they are often confused and indistinguishable from one another. So both they run with a low tolerance for frustration, high irritability and even outbursts of anger which do not correspond to the objective characteristics of the fact that causes them to explode. It is also possible that in either case, it is difficult to delay rewards and “Fluctuations” (more or less marked) in mood. Since treatment is different in each case, the particular disorder you have or if there is an underlying comorbidity should be identified.
There are a few differences between bipolar disorder and ADHD to consider when evaluating. To distinguish one from the other, it is essential to take into account the following: in bipolar disorder there is a long family history of this same clinical picture, there are periods of great expansion of mood , highlights depressive irritable affectivity, emotional twists are more frequent / severe and there is a tendency to grandiosity in the way we think about ourselves.
Finally, it has also been described that more or less half of children with bipolar disorder have inappropriate sexual behaviors, or what is the same, which do not correspond to their age and which takes place in contexts where they are disruptive. (masturbation in public places, for example). All this without a history of abuse (context in which these habits can arise in a common way).
In addition, also they express with some frequency that they do not need sleepSomething that should be distinguished from the reluctance to lie down in ADHD.
Addictions are also a very big problem in ADHD, especially when you reach adolescence., Where the danger of drug addiction is quintupled. Research on such an essential question yields figures between 10 and 24% of comorbid dependence, reaching maximum prevalence of 52% in some studies. It is always believed that there is some sort of preference for stimulant drugs, the truth is that a clear pattern is not distinguished, describing all kinds of use (most often being addiction to several substances at once) .
A very large percentage of adolescents with ADHD / substance abuse have exhibited problematic behavior prior to this stage, which may include covert thefts or other activities that violate the rights of others. There is also evidence of an early onset of recreational use (often before the age of fifteen) as well as a significantly greater presence of antisocial personality traits (50% in adolescents with ADHD) and addiction and 25% in those with ADHD only).
It is known that the presence of ADHD symptoms negatively affects the prognosis of addiction, And that on the other hand the use of substances alters the effectiveness of the drugs which are usually administered in order to regulate their symptoms (in particular the stimulants of the central nervous system). It should not be forgotten, on the other hand, that the therapeutic approach with such drugs requires the closest possible follow-up in the event of dependence, to avoid an inappropriate use of these.
To finish, working with family is always essential, Aims to promote tools that minimize the risk of relapses and preserve relational balance. Any drug use is a difficult situation at the level of the social group and requires adjusting the different roles they have played so far. On the other hand, at the systemic level, there is what appears to be an indissoluble functional and two-way connection: ADHD is more common in families where there is addiction and addiction is more common in families where there is ADHD. .
5. Behavior disorders
Behavioral disturbances are common in children with ADHD. These are acts which cause harm to other people or to the child himself, and which are linked to a high level of conflict in the family and at school. Examples can be bullying, talking to parents that includes scenes of physical / verbal abuse, petty theft and scolding. The goal is to gain a secondary advantage. All of this would certainly result in aggressive, stimulating and impulsive behaviors.
When ADHD encounters these difficulties, it is understood as a specific variant in which family stress levels reach a higher threshold than conventional ADHD. And it is that in general symptoms of inattention, impulsivity and hyperactivity are much more intense; and end up torpedoing the child’s efforts to overcome historical milestones associated with each stage of development (which isolates him from pro-socially inclined peer groups and separates him into marginal groups where dissocial behaviors gain value. and reinforcing).
The family history of such a comorbid case is characterized by 1 bad parenting, poor monitoring of the child’s habits outside the home and even abuse of all kinds and harshness. These are therefore environments with an exorbitant level of social conflict, and even families at extreme risk of exclusion. It is not uncommon for one or both of these parents to suffer from a serious mental illness (including antisocial disorders or chemical and non-chemical addictions). This situation also increases the risk to the child in drug use, aggravating all his problems, as we saw in a previous section.
Suicide is not a disorder in itself, but a dramatic and painful consequence, often involving a long history of psychological pain. In fact, up to 50% of teens who try or succeed have a mental health problem, With an average evolution of two years taking the time of the suicide act as a reference. Patients diagnosed with ADHD are known to be more likely to engage in suicidal behavior, have autolytic ideation, and even injure themselves of varying degrees.
The literature on this subject is consistent in designating adolescence and adulthood as the periods of greatest vulnerability, to the point that 10% of adults with ADHD have attempted suicide at least once and that 5% die precisely because of this cause. The risk increases when living with major depression, a behavioral problem or drug addiction; and also in the case where the patient is a man. Therefore, when providing articulated treatment for subjects with ADHD and some comorbidity, this possibility should be kept in mind.
The cognitive impairments exhibited by these patients, particularly in areas such as attention and behavioral inhibition, are associated with an increased risk of suicidal behavior. To such an extent, many studies on the epidemiology of suicide focus on ADHD as a risk factor for this important health and social problem.
- Klassen, L., Katzman, M. and Chokka, P. (2009). ADHD in adults and their comorbidities, with an emphasis on bipolar disorder. Journal of Affective Disorders, 124, 1-8.
- Sherman, J. and Tarnow, J. (2013). What are the common ADHD comorbidities? Psychiatric Times, 30, 47-59.