ADHD: Comorbidities in Children


compiledby Teresa Binstock for
Generation Rescue
June 2008

ADHD: Comorbidities in Children



: ADHD has specifid criteria (DSM-IV). However, if other signficant traits are present, one or more additional diagnostic labels may be justified. Many studies describe traits which can be comorbid with ADHD. Other studies describe the efficacy of various treatments. PubMed offers far more citations than the sampling presented here.

As of June 28, 2008, the following PubMed search generated more than 2400 citations:

(ADHD OR (attention AND deficit)) AND comorbi*

Many such studies focus upon children; similarly, many focus upon adults.

1. AD/HD Co-Morbidity: What's Under the Tip of the Iceberg?
Carol E. Watkins, M.D.

2. Managing ADHD and Comorbidity
Scott H Kollins, PhD

3. Have there been changes in children's psychosomatic symptoms? A 10-year comparison from Finland

Santalahti P et al.
Pediatrics. 2005 Apr;115(4):e434-42.

OBJECTIVES: The aims of the study were to determine whether the prevalence of children's somatic symptoms, such as headache, abdominal pain, other pain, and nausea and vomiting, changed from 1989 to 1999 and to study the similarity of parents' and children's reports of the child's symptoms. Furthermore, the aims were to explore possible comorbidity in somatic symptoms and to investigate the associations between somatic and psychiatric symptoms. METHODS: Two cross-sectional, representative samples were compared. All children born in 1981 (1989 sample, n = 985) and 1991 (1999 sample, n = 962) and living in selected school districts in southwest Finland served as study samples. The response rate for the 1989 sample was 95% and that for the 1999 sample was 86%. Both children and parents were asked about the children's somatic symptoms, whereas parents, children, and teachers were asked about psychiatric symptoms. To study psychiatric symptoms, the Children's Depression Inventory and Rutter's parent and teacher scales were used. RESULTS: The prevalence of frequent headaches and abdominal pain increased somewhat from 1989 to 1999. Parents often failed to recognize their children's psychosomatic problems. Child-reported somatic symptoms were associated with conduct and hyperactivity symptoms, in addition to a previously well-documented association with depression. In associations between somatic symptoms and psychiatric symptoms, there were some differences between the 1989 and 1999 samples. CONCLUSIONS: In clinical work, questions about somatic and psychiatric symptoms should also be addressed to children themselves, because parents and teachers do not always recognize children's symptoms. When somatic problems are being evaluated, psychiatric symptoms should be asked about, and vice versa. More research is needed to explore the reasons for the increased prevalence of somatic symptoms and their associations with psychiatric symptoms.
PMID: 15805346

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4. Comorbidity of ADHD and reading disability among clinic-referred children

August GJ, Garfinkel BD.
J Abnorm Child Psychol. 1990 Feb;18(1):29-45.

Of a consecutive series of 115 boys diagnosed in a university outpatient clinic as ADHD, 39% also demonstrated a specific reading disability. Pure ADHD patients were compared with mixed ADHD + RD and normal controls on a battery of cognitive and attentional measures. The aim was to determine whether a distinct pattern of deficits would distinguish the groups. Both ADHD subgroups performed significantly worse than controls on measures of sequential memory and attentional tasks involving impulse control and planful organization. Only ADHD + RD boys differed from controls on measures or rapid word naming and vocabulary. The results are discussed within the framework of an automatic versus effortful information-processing model.
PMID: 2324400

5. Comorbidity in ADHD: implications for research, practice, and DSM-V

Jensen PS, Martin D, Cantwell DP.
J Am Acad Child Adolesc Psychiatry. 1997 Aug;36(8):1065-79.

OBJECTIVE: Since the introduction of DSM-III/III-R, clinicians and investigators have shown increasing interest in the study of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). Better understanding ADHD comorbidity patterns is needed to guide treatment, research and future classification approaches. METHOD: The ADHD literature from the past 15 years was reviewed to (1) explore the most prevalent patterns of ADHD comorbidity; (2) examine the correlates and longitudinal predictors of comorbidity; and (3) determine the extent to which comorbid patterns convey unique information concerning ADHD etiology, treatment and outcomes. To identify potential new syndromes, the authors examined comorbid patterns based on eight validational criteria. RESULTS: The largest available body of literature concerned the comorbidity with ADHD and conduct disorder/aggression, with a substantially smaller amount of data concerning other comorbid conditions. In many areas the literature was sparse, and pertinent questions concerning comorbidity patterns remain unexplored. Nonetheless available data warrant the delineation of two new subclassifications of ADHD: (1) ADHD aggressive subtype, and (2) ADHD, anxious subtype. CONCLUSIONS: Additional studies of the frequency of comorbidity and associated factors are greatly needed to include studies of differential effects of treatment of children with various comorbid ADHD disorders, as well as of ADHD children who differ on etiological factors.
PMID: 9256586

6. Associations between childhood asthma and ADHD: issues of psychiatric comorbidity and familiality

Biederman J, Milberger S, Faraone SV, Guite J, Warburton R.
J Am Acad Child Adolesc Psychiatry. 1994 Jul-Aug;33(6):842-8.

OBJECTIVE: In this paper we evaluate the association between asthma and attention-deficit hyperactivity disorder (ADHD), addressing issues of comorbidity and familiality by formulating and testing competing hypotheses. METHOD: Subjects were 6- to 17-year-old boys with DSM-III-R ADHD (N = 140) and normal controls (N = 120) and their first-degree relatives. Information on asthma was obtained from the mothers in a standardized manner blind to the proband's clinical status. RESULTS: The risk for asthma did not meaningfully differ between ADHD and control children. Relatives of ADHD probands with and without asthma were at significantly greater risk for ADHD than relatives of normal controls. In contrast, the risk for asthma was significantly elevated only among relatives of children with ADHD plus asthma. CONCLUSIONS: These findings argue against a substantial etiological or pathophysiological relationship between the two conditions but suggest that ADHD and asthma are independently transmitted in families. Thus, the observation of ADHD symptoms in an asthmatic child should not be dismissed out of hand as being a consequence of asthma since many asthmatic ADHD children may actually have ADHD.
PMID: 8083141

7. Attention deficit disorder and allergy: a neurochemical model of the relation between the illnesses

Marshall P.
Psychol Bull. 1989 Nov;106(3):434-46.

Empirical studies suggest that allergies play an etiological role in a small subgroup of children who suffer from attention deficit-hyperactivity disorder (ADHD). Research indicates that allergic reactions results in cholinergic hyperresponsiveness and beta-adrenergic hyporesponsiveness in the autonomic nervous system. Evidence is reviewed that similar imbalances in central nervous system cholinergic/adrenergic activity play a causal role in manic and depressive behaviors. It is hypothesized that allergic reactions engender cholinergic/adrenergic activity imbalances in the central nervous system, leading to poorly regulated arousal levels and ADHD behaviors in some children.
PMID: 2682719

8. Reexamining the familial association between asthma and ADHD in girls

Hammerness P et al.
J Atten Disord. 2005 Feb;8(3):136-43.

The objective of this study is to further evaluate the association between asthma and ADHD, addressing issues of familiality in female probands. A case control study of referred ADHD proband girls, controls, and relatives are used. Participants include 140 ADHD proband girls and 122 non-ADHD comparisons, with 417 and 369 first-degree biological relatives, respectively. Relatives are stratified into four groups according to proband ADHD and asthma status. The authors compare rates of asthma and ADHD in relatives. ADHD does not increase the risk for asthma in probands. Patterns of familial aggregation are mostly consistent with independent transmission of ADHD and asthma in families of girl probands. The results extend to female probands' previously reported findings that asthma and ADHD are independently transmitted in families. These findings further support the conclusion that ADHD symptoms should not be dismissed as part of asthma symptomatology or a consequence of its treatment.
PMID: 16009662

9. Psychiatric comorbidity associated with DSM-IV ADHD in a nonreferred sample of twins

Willcutt EG, Pennington BF, Chhabildas NA, Friedman MC, Alexander J.
J Am Acad Child Adolesc Psychiatry. 1999 Nov;38(11):1355-62.

OBJECTIVE: To test the external validity of the dimensions and subtypes of DSM-IV attention-deficit/hyperactivity disorder (ADHD) by assessing the prevalence of psychiatric comorbidity. METHOD: Eight- to 18-year-old twins with ADHD (n = 105) and without ADHD (n = 95) were recruited through local school districts. Comorbid disorders were assessed by structured diagnostic interviews with the parent and child and by a behavioral rating scale completed by the child's classroom teacher. RESULTS: Symptoms of inattention were associated with lower intelligence and higher levels of depression, whereas symptoms of hyperactivity-impulsivity were associated more strongly with symptoms of oppositional defiant disorder (ODD) and conduct disorder (CD). All DSM-IV subtypes were associated with higher rates of ODD and CD in comparison with controls, and the combined type was associated with more disruptive behavior disorder symptoms than the other 2 subtypes. The combined type and predominantly inattentive type were associated with more symptoms of depression than controls or the predominantly hyperactive-impulsive type. CONCLUSIONS: These results provide support for the discriminant validity of the dimensions and subtypes of DSM-IV ADHD and suggest that clinicians should carefully screen for comorbid disorders as part of a comprehensive assessment of ADHD.
PMID: 10560221

10. Symptom profiles in children with ADHD: effects of comorbidity and gender

Newcorn JH et al.
J Am Acad Child Adolesc Psychiatry. 2001 Feb;40(2):137-46.

OBJECTIVE: To examine ratings and objective measures of attention-deficit/hyperactivity disorder (ADHD) symptoms to assess whether ADHD children with and without comorbid conditions have equally high levels of core symptoms and whether symptom profiles differ as a function of comorbidity and gender. METHOD: Four hundred ninety-eight children from the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) were divided into comorbid groups based on the parent Diagnostic Interview Schedule for Children and assessed via parents' and teachers' Swanson, Nolan, and Pelham (SNAP) ratings and a continuous performance test (CPT). Comorbidity and gender effects were examined using analyses of covariance controlled for age and site. RESULTS: CPT inattention, impulsivity, and dyscontrol errors were high in all ADHD groups. Children with ADHD + oppositional defiant or conduct disorder were rated as more impulsive than inattentive, while children with ADHD + anxiety disorders (ANX) were relatively more inattentive than impulsive. Girls were less impaired than boys on most ratings and several CPT indices, particularly impulsivity, and girls with ADHD + ANX made fewer CPT impulsivity errors than girls with ADHD-only. CONCLUSIONS: Children with ADHD have high levels of core symptoms as measured by rating scales and CPT, irrespective of comorbidity. However, there are important differences in symptomatology as a function of comorbidity and gender.
PMID: 11214601

11. ADHD comorbidity findings from the MTA study: comparing comorbid subgroups

Jensen PS et al.
J Am Acad Child Adolesc Psychiatry. 2001 Feb;40(2):147-58.

OBJECTIVES: Previous research has been inconclusive whether attention-deficit/hyperactivity disorder (ADHD), when comorbid with disruptive disorders (oppositional defiant disorder [ODD] or conduct disorder [CD]), with the internalizing disorders (anxiety and/or depression), or with both, should constitute separate clinical entities. Determination of the clinical significance of potential ADHD + internalizing disorder or ADHD + ODD/CD syndromes could yield better diagnostic decision-making, treatment planning, and treatment outcomes. METHOD: Drawing upon cross-sectional and longitudinal information from 579 children (aged 7-9.9 years) with ADHD participating in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA), investigators applied validational criteria to compare ADHD subjects with and without comorbid internalizing disorders and ODD/CD. RESULTS: Substantial evidence of main effects of internalizing and externalizing comorbid disorders was found. Moderate evidence of interactions of parent-reported anxiety and ODD/CD status were noted on response to treatment, indicating that children with ADHD and anxiety disorders (but no ODD/CD) were likely to respond equally well to the MTA behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to MTA medication treatments (with or without behavioral treatments), while children with multiple comorbid disorders (anxiety and ODD/CD) responded optimally to combined (medication and behavioral) treatments. CONCLUSIONS: Findings indicate that three clinical profiles, ADHD co-occurring with internalizing disorders (principally parent-reported anxiety disorders) absent any concurrent disruptive disorder (ADHD + ANX), ADHD co-occurring with ODD/CD but no anxiety (ADHD + ODD/CD), and ADHD with both anxiety and ODD/CD (ADHD + ANX + ODD/CD) may be sufficiently distinct to warrant classification as ADHD subtypes different from "pure" ADHD with neither comorbidity. Future clinical, etiological, and genetics research should explore the merits of these three ADHD classification options.
PMID: 11211363

12. The comorbidity of ADHD in the general population of Swedish school-age children

Kadesjö B, Gillberg C.
J Child Psychol Psychiatry. 2001 May;42(4):487-92.

This study examined patterns of comorbid/associated diagnoses and associated problems in a population sample of children with and without DSM-III-R attention-deficit hyperactivity disorder (ADHD). Half (N = 409) of a mainstream school population of Swedish 7-year-olds were clinically examined, and parents and teachers were interviewed and completed questionnaires. The children were followed up 2-4 years later. Eighty-seven per cent of children meeting full criteria for ADHD (N = 15) had one or more and 67% at least two--comorbid diagnoses. The most common comorbidities were oppositional defiant disorder and developmental coordination disorder. Children with subthreshold ADHD (N = 42) also had very high rates of comorbid diagnoses (71% and 36%), whereas those without ADHD (N = 352) had much lower rates (17% and 3%). The rate of associated school adjustment, learning, and behaviour problems at follow-up was very high in the ADHD groups. We concluded that pure ADHD is rare even in a general population sample. Thus, studies reporting on ADHD cases without comorbidity probably refer to highly atypical samples. By and large, such studies cannot inform rational clinical decisions.
PMID: 11383964

13. Psychiatric comorbidity and functioning in clinically referred preschool children and school-age youths with ADHD

Wilens TE, Biederman J, Brown S, Tanguay S, Monuteaux MC, Blake C, Spencer TJ.
J Am Acad Child Adolesc Psychiatry. 2002 Mar;41(3):262-8.

OBJECTIVE: Although the literature documents that attention-deficit/hyperactivity disorder (ADHD) commonly onsets prior to age 6, little is known about the disorder in preschool children. We evaluated the clinical characteristics, psychiatric comorbidity, and functioning of preschool children and school-age youths with ADHD referred to a pediatric psychiatric clinic for evaluation. METHOD: Structured psychiatric interviews assessing lifetime psychopathology by DSM-III-R criteria were completed with parents about their children. Family, social, and overall functioning were also assessed at intake. RESULTS: We identified 165 children with ADHD aged 4 to 6 years (preschool children) and 381 youths aged 7 to 9 years (school-age) with ADHD. Despite being younger, preschool children had similar rates of comorbid psychopathology compared with school-age youths with ADHD. There was an earlier onset of ADHD and co-occurring psychopathology in the preschool children compared to school-age youths. Both preschool children and school-age youths had substantial impairment in school, social, and overall functioning. CONCLUSIONS: The results of this study suggest that despite being significantly younger, clinically referred preschool children with ADHD are reminiscent of school-age youths with ADHD in the quality of ADHD, high rates of comorbid psychopathology, and impaired functioning. Follow-up of these clinically referred preschool children with ADHD to evaluate the stability of their diagnoses, treatment response, and their long-term outcome are necessary.
PMID: 11886020

14. Examining the comorbidity of ADHD-related behaviours and conduct problems using a twin study design

Thapar A, Harrington R, McGuffin P.
Br J Psychiatry. 2001 Sep;179:224-9.

BACKGROUND: Although attention-deficit hyperactivity disorder (ADHD) and conduct disorder (CD) frequently co-occur, the underlying mechanisms for this comorbidity are not well understood. AIMS: To examine whether ADHD and conduct problems share common risk factors and whether ADHD+CD is a more heritable variant of ADHD. METHOD: Questionnaires were sent to 2846 families. Parent-rated data were obtained for 2082 twin pairs and analysed using bivariate genetic analysis and a liability threshold model approach. RESULTS: The overlap of ADHD and conduct problems was explained by common genetic and non-shared environmental factors influencing both categories. Nevertheless, the two categories appeared to be partly distinct in that additional environmental factors influenced conduct problems. It appeared that ADHD+CD was a genetically more severe variant of ADHD. CONCLUSIONS: Conduct problems and ADHD share a common genetic aetiology; ADHD+CD appears to be a more severe subtype in terms of genetic loading as well as clinical severity.
PMID: 11532799

15. Gender differences in ADHD subtype comorbidity

Levy F, Hay DA, Bennett KS, McStephen M.
J Am Acad Child Adolesc Psychiatry. 2005 Apr;44(4):368-76.

OBJECTIVE: To examine gender differences in attention-deficit/hyperactivity disorder ("ADHD") symptom comorbidity with "oppositional defiant disorder", "conduct disorder", "separation anxiety disorder", "generalized anxiety disorder", speech therapy, and remedial reading in children. METHOD: From 1994 to 1995, data from a large sample (N = 4,371) of twins and siblings studied in the Australian Twin ADHD Project were obtained by mailed DSM-IV-based questionnaires, investigating patterns of comorbidity in the three subtypes of "ADHD": "inattentive", "hyperactive/impulsive", and "combined". A total of 1,550 questionnaires were returned (87%) over the next 12 to 18 months. RESULTS: Analysis of variance showed significant between-group differences in males and females for inattention and hyperactive/impulsive symptom counts with higher rates of "oppositional defiant disorder" and "conduct disorder" in males, and higher rates of "separation anxiety disorder" in females indicating internalizing disorders are more common in females and externalizing disorders are occurring more often in males. Differences were found between the "ADHD" subtypes and the no ADHD category for all comorbid conditions, for both males and females. Children without ADHD consistently had fewer symptoms, while children with the combined subtype showed consistently more comorbid symptoms indicating a strong relationship between high rates of externalizing symptoms and high rates of internalizing symptoms. Gender differences in speech therapy were significant only for the children without ADHD. The rates of "separation anxiety disorder" were higher in females with the "inattention" subtype and the rate of "generalized anxiety disorder" higher for females with the "combined" subtype, indicating that the subtypes of ADHD were associated with these internalizing disorders in different ways. CONCLUSIONS: Although comorbidity differs among ADHD subtypes, there were no significant gender differences in comorbidity for externalizing disorders. Inattentive girls may present with anxiety. Clinical approaches for both males and females should be sensitive to possible language and reading problems.
PMID: 15782084

16. Comorbidity between ADHD and symptoms of bipolar disorder in a community sample of children and adolescents

Reich W, Neuman RJ, Volk HE, Joyner CA, Todd RD.
Twin Res Hum Genet. 2005 Oct;8(5):459-66.

The prevalence and frequency of comorbidity of possible bipolar disorder was examined with attention-deficit hyperactivity disorder (ADHD) in a nonreferred population of twins. Children and adolescents aged 7 to 18 years with a history of manic symptoms were identified from a population-based twin sample obtained from state birth records (n = 1610). The sample was enriched for ADHD; however, there was also a random control sample (n = 466), which allowed a look at the population prevalence of the disorder. Juveniles with threshold or below threshold manic episodes were further assessed for comorbidity with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) and population-defined ADHD subtypes (from latent class analysis) using Fisher's exact test. Nine juveniles who exhibited DSM-IV manic (n = 1), hypomanic (n = 2) or below threshold episodes (n = 6) were identified. The population prevalence of broadly defined mania in the random sample was 0.2%. The possible manic episodes showed significant comorbidity with population-defined severe combined and talkative ADHD subtypes. It can be concluded that there is a significant association of bipolar symptoms with two population-defined subtypes of ADHD. Episodes of possible bipolar disorders as defined by DSM-IV are uncommon in this nonreferred sample. Children and adolescents with ADHD appear to be only modestly at increased risk for bipolar disorders.
PMID: 16212835

17. ADHD and comorbidity in childhood

Spencer TJ.
J Clin Psychiatry. 2006;67 Suppl 8:27-31.

In recent years, evidence has been accumulating regarding high levels of comorbidity between attention-deficit/hyperactivity disorder (ADHD) and a number of disorders, including mood and anxiety disorders and conduct disorder. Thus, ADHD is most likely a group of conditions, rather than a single homogeneous clinical entity, with potentially different etiologic and modifying risk factors and different outcomes. Follow-up studies of children with ADHD indicate that subgroups of subjects with ADHD and comorbid disorders have a poorer outcome as evidenced by significantly greater social, emotional, and psychological difficulties. Investigation of these issues should help to clarify the etiology, course, and outcome of ADHD.
PMID: 16961427

18. ADHD correlates, comorbidity, and impairment in community and treated samples of children and adolescents

Bauermeister JJ et al.
J Abnorm Child Psychol. 2007 Dec;35(6):883-98.

Patterns of correlates, comorbidity and impairment associated with attention-deficit hyperactivity disorder (ADHD) in children and youth were examined in representative samples from the community and from treatment facilities serving medically indigent youth in Puerto Rico. Information from caretakers and youths was obtained using the Diagnostic Interview Schedule for Children, (version IV), measures of global impairment, and a battery of potential correlates. In the community (N = 1,896) and the treated samples (N = 763), 7.5 and 26.2% of the children, respectively, met criteria for DSM-IV ADHD in the previous year. Although the prevalence rates and degree of impairment differed, the general patterns of correlates, comorbidity and impairment were similar in both populations. The exceptions were associated with conduct disorder, anxiety, impairment in the ADHD comorbid group, and age factors that appeared to be related to selection into treatment.
PMID: 17505876

19. Comorbidity with ADHD decreases response to pharmacotherapy in children and adolescents with acute mania: evidence from a metaanalysis

Consoli A, Bouzamondo A, Guilé JM, Lechat P, Cohen D.
Can J Psychiatry. 2007 May;52(5):323-8.

OBJECTIVE: To assess whether comorbid attention-deficit hyperactivity disorder (ADHD) influences response to treatment in young patients with acute mania. METHODS: We conducted a metaanalysis of 5 open trials of 100, 35, 41, 60, and 37 children and adolescents. The pooled group included 273 children and adolescents with bipolar disorder (BD), divided into 2 subgroups: those with (n = 132), and those without (n = 141), ADHD comorbidity. RESULTS: There was a moderate and significant reduction in relative risk (RR) favouring treatment response in children and adolescents with BD but without ADHD comorbidity (RR 0.822; 95% CI, 0.69 to 0.97; P = 0.021). The negative effect of ADHD comorbidity on treatment response was more significant in studies including adolescents only or subjects with BD I only. CONCLUSION: These findings suggest that children and adolescents with BD and ADHD tend to be less responsive to drugs used in treatment of acute mania.
PMID: 17542383

20. Comorbidity of Psychiatric Disorders and Parental Psychiatric Disorder of ADHD Children

Ghanizadeh A, Mohammadi MR, Moini R.
J Atten Disord. 2008 Mar 4.

Objective: To study the psychiatric comorbidity of a clinical sample of children with ADHD and the psychiatric disorders in their parents. Method: Structured psychiatric interviews assessing lifetime psychiatric disorders by DSM-IV criteria, using the Farsi version of the Schedule for Affective Disorders and Schizophrenia. Results: The mean age of the children was 8.7, mothers, 40.1, and fathers, 34.6 years. Only 7.6% of the boys and 21.7% of the girls manifested ADHD without any other psychiatric comorbidity. The most common comorbid disorders were disruptive behavior disorders and anxiety disorders. The prevalence of lifetime ADHD in the parents was 45.8% and 17.7%, respectively. The rate for major depressive disorder in mothers and fathers was 48.1% and 43.0%, respectively. Discussion: The clinical sample of ADHD children typically had at least one other psychiatric disorder, usually oppositional defiant disorder in boys and anxiety disorders in girls. The most common psychiatric disorder in the parents was mood disorder.
PMID: 18319376

21. Sleep disturbances in 50 children with attention-deficit hyperactivity disorder

Neves SN, Reimão R.
Arq Neuropsiquiatr. 2007 Jun;65(2A):228-33.

OBJECTIVE: This study assesses the relationship between sleep disturbances (SD) and attention-deficit and hyperactivity disorder (ADHD) to characterize clinical features and associated problems. METHOD: The medical records of 50 children and adolescents ranging in age from 4 to 17 years with ADHD without the diagnosis of mental retardation or pervasive developmental disorders were reviewed. RESULTS: Significant relationships were found between SD and drug therapy (p<0.01), co-morbidity (p<0.01) and greater adherence to treatment prescribed for ADHD disorders (p<0.05). CONCLUSION: The results of this study suggest that SD are an important problem in children with ADHD and may be linked to increased symptoms.
PMID: 17607419

22. ECI-4 screening of attention deficit-hyperactivity disorder and co-morbidity in Mexican preschool children: preliminary results

Poblano A, Romero E.
Arq Neuropsiquiatr. 2006 Dec;64(4):932-6.

OBJECTIVE: To examine prospectively usefulness of Early Childhood Inventory-4 (ECI-4) in identifying attention deficit-hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). METHOD: A sample of children <6 years of age were evaluated in school settings with ECI-4 and results compared with those of Conners Rating Scales-Revised (CRS-R) 6 months later. Sample consisted of 34 healthy children (20 boys, 14 girls) prospectively followed-up. RESULTS: Frequency of children fulfill DSM-IV AD-HD criteria in ECI-4 parent scale was 17%, and in teacher scale was 32%. Frequency of children fulfill DSM-IV AD-HD criteria in parent CRS-R was 20%, and for teacher questionnaire was 23%. Correlations were significant among teacher ECI-4 and both teacher and parent CRS-R scales. Sensitivity and specificity of teacher and parent ECI-4 scales were not good. Frequency of ODD identified in parent ECI-4 scale was 5%, and for teacher 17%. Frequency of ODD in CRS-R for parents and teachers questionnaires was 17%. CD was not identified by parents in ECI-4 scale, but in teacher scale frequency was 14%. CONCLUSION: These facts support partially the use of ECI-4 screening of ADHD in Spanish-speaking preschool children.
PMID: 17220998

23. Neural circuitry engaged during unsuccessful motor inhibition in pediatric bipolar disorder.

Leibenluft E et al.
Am J Psychiatry. 2007 Jan;164(1):52-60.

OBJECTIVE: Deficits in motor inhibition may contribute to impulsivity and irritability in children with bipolar disorder. Studies of the neural circuitry engaged during failed motor inhibition in pediatric bipolar disorder may increase our understanding of the pathophysiology of the illness. The authors tested the hypothesis that children with bipolar disorder and comparison subjects would differ in ventral prefrontal cortex, striatal, and anterior cingulate activation during unsuccessful motor inhibition. They also compared activation in medicated versus unmedicated children with bipolar disorder and in children with bipolar disorder and attention deficit hyperactivity disorder (ADHD) versus those with bipolar disorder without ADHD. METHOD: The authors conducted an event-related functional magnetic resonance imaging study comparing neural activation in children with bipolar disorder and healthy comparison subjects while they performed a motor inhibition task. The study group included 26 children with bipolar disorder (13 unmedicated and 15 with ADHD) and 17 comparison subjects matched by age, gender, and IQ. RESULTS: On failed inhibitory trials, comparison subjects showed greater bilateral striatal and right ventral prefrontal cortex activation than did patients. These deficits were present in unmedicated patients, but the role of ADHD in mediating them was unclear. CONCLUSIONS: In relation to comparison subjects, children with bipolar disorder may have deficits in their ability to engage striatal structures and the right ventral prefrontal cortex during unsuccessful inhibition. Further research should ascertain the contribution of ADHD to these deficits and the role that such deficits may play in the emotional and behavioral dysregulation characteristic of bipolar disorder.
PMID: 17202544

24. The impact of ADHD and autism spectrum disorders on temperament, character, and personality development

Anckarsäter H et al.
Am J Psychiatry. 2006 Jul;163(7):1239-44.

OBJECTIVE: The authors describe personality development and disorders in relation to symptoms of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorders. METHOD: Consecutive adults referred for neuropsychiatric investigation (N=240) were assessed for current and lifetime ADHD and autism spectrum disorders and completed the Temperament and Character Inventory. In a subgroup of subjects (N=174), presence of axis II personality disorders was also assessed with the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II). RESULTS: Patients with ADHD reported high novelty seeking and high harm avoidance. Patients with autism spectrum disorders reported low novelty seeking, low reward dependence, and high harm avoidance. Character scores (self-directedness and cooperativeness) were extremely low among subjects with neuropsychiatric disorders, indicating a high overall prevalence of personality disorders, which was confirmed with the SCID-II. Cluster B personality disorders were more common in subjects with ADHD, while cluster A and C disorders were more common in those with autism spectrum disorders. The overlap between DSM-IV personality disorder categories was high, and they seem less clinically useful in this context. CONCLUSIONS: ADHD and autism spectrum disorders are associated with specific temperament configurations and an increased risk of personality disorders and deficits in character maturation.
PMID: 16816230

25. Differences in brain chemistry in children and adolescents with attention deficit hyperactivity disorder with and without comorbid bipolar disorder: a proton magnetic resonance spectroscopy study

Moore CM et al.
Am J Psychiatry. 2006 Feb;163(2):316-8.

OBJECTIVE: The authors' goal was to investigate phosphatidylinositol and glutamatergic metabolism in the anterior cingulate cortex of children and adolescents with attention deficit hyperactivity disorder (ADHD) alone, children with ADHD plus bipolar disorder, and children with no axis I diagnosis. METHOD: Proton spectra were acquired from a 4.8-ml voxel placed in the anterior cingulate cortex of 30 subjects who were 6 to 13 years old. Fifteen subjects had ADHD and no comorbid disorder, eight had ADHD plus bipolar disorder, and seven were healthy comparison subjects. RESULTS: Children with ADHD had a significantly higher ratio of glutamate plus glutamine to myo-inositol-containing compounds than children with ADHD plus bipolar disorder and healthy children. CONCLUSIONS: myo-Inositol-containing compounds may provide information on the action of antimanic treatments such as lithium, valproate, and carbamazepine. Glutamate and glutamine are measures of glutamatergic neurotransmission and thus may also reflect changes in serotonin and dopamine pathways.
PMID: 16449488

26. The hard work of growing up with ADHD

Martin A.
Am J Psychiatry. 2005 Sep;162(9):1575-7.
PMID: 16135614

27. Inattention/hyperactivity and aggression from early childhood to adolescence: heterogeneity of trajectories and differential influence of family environment characteristics.

Jester JM et al.
Dev Psychopathol. 2005 Winter;17(1):99-125.

Inattention/hyperactivity and aggressive behavior problems were measured in 335 children from school entry throughout adolescence, at 3-year intervals. Children were participants in a high-risk prospective study of substance use disorders and comorbid problems. A parallel process latent growth model found aggressive behavior decreasing throughout childhood and adolescence, whereas inattentive/hyperactive behavior levels were constant. Growth mixture modeling, in which developmental trajectories are statistically classified, found two classes for inattention/hyperactivity and two for aggressive behavior, resulting in a total of four trajectory classes. Different influences of the family environment predicted development of the two types of behavior problems when the other behavior problem was held constant. Lower emotional support and lower intellectual stimulation by the parents in early childhood predicted membership in the high problem class of inattention/hyperactivity when the trajectory of aggression was held constant. Conversely, conflict and lack of cohesiveness in the family environment predicted membership in a worse developmental trajectory of aggressive behavior when the inattention/hyperactivity trajectories were held constant. The implications of these findings for the development of inattention/hyperactivity and for the development of risk for the emergence of substance use disorders are discussed.
PMID: 15971762

28. Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications

Wolraich ML, Wibbelsman CJ, Brown TE, Evans SW, Gotlieb EM, Knight JR, Ross EC, Shubiner HH, Wender EH, Wilens T.
Pediatrics. 2005 Jun;115(6):1734-46.

Attention-deficit/hyperactivity disorder (ADHD) is the most common mental disorder in childhood, and primary care clinicians provide a major component of the care for children with ADHD. However, because of limited available evidence, the American Academy of Pediatrics guidelines did not include adolescents and young adults. Contrary to previous beliefs, it has become clear that, in most cases, ADHD does not resolve once children enter puberty. This article reviews the current evidence about the diagnosis and treatment of adolescents and young adults with ADHD and describes how the information informs practice. It describes some of the unique characteristics observed among adolescents, as well as how the core symptoms change with maturity. The diagnostic process is discussed, as well as approaches to the care of adolescents to improve adherences. Both psychosocial and pharmacologic interventions are reviewed, and there is a discussion of these patients' transition into young adulthood. The article also indicates that research is needed to identify the unique adolescent characteristics of ADHD and effective psychosocial and pharmacologic treatments.
PMID: 15930238

29. Common psychological disorders in childhood.

Ciechomski L, Blashki G, Tonge B.
Aust Fam Physician. 2004 Dec;33(12):997-1003.

BACKGROUND: Children with anxiety, attention deficit hyperactivity, and disruptive behaviour disorders are frequently seen in general practice and often present with somatic complaints, comorbidity and complex family relationships. OBJECTIVE: This article presents an approach to assessment including useful clinical questions, case diagnostic criteria and recommendations on psychometric tools for general practice. DISCUSSION: Key management principles including psychological and pharmacological approaches are outlined, and a multidisciplinary approach incorporating specialist care is recommended.
PMID: 15630921

30. Psychiatric and medical comorbidities of bipolar disorder.

Krishnan KR.
Psychosom Med. 2005 Jan-Feb;67(1):1-8.

OBJECTIVES: This review summarizes the literature on psychiatric and medical comorbidities in bipolar disorder. The coexistence of other Axis I disorders with bipolar disorder complicates psychiatric diagnosis and treatment. Conversely, symptom overlap in DSM-IV diagnoses hinders definition and recognition of true comorbidity. Psychiatric comorbidity is often associated with earlier onset of bipolar symptoms, more severe course, poorer treatment compliance, and worse outcomes related to suicide and other complications. Medical comorbidity may be exacerbated or caused by pharmacotherapy of bipolar symptoms. METHODS: Articles were obtained by searching MEDLINE from 1970 to present with the following search words: bipolar disorder AND, comorbidity, anxiety disorders, eating disorder, alcohol abuse, substance abuse, ADHD, personality disorders, borderline personality disorder, medical disorders, hypothyroidism, obesity, diabetes mellitus, multiple sclerosis, lithium, valproate, lamotrigine, carbamazepine, atypical antipsychotics. Articles were prioritized for inclusion based on the following considerations: sample size, use of standardized diagnostic criteria and validated methods of assessment, sequencing of disorders, quality of presentation. RESULTS: Although the literature establishes a strong association between bipolar disorder and substance abuse, the direction of causality is uncertain. An association is also seen with anxiety disorders, attention-deficit/hyperactivity disorder, and eating disorders, as well as cyclothymia and other axis II personality disorders. Medical disorders accompany bipolar disorder at rates greater than predicted by chance. However, it is often unclear whether a medical disorder is truly comorbid, a consequence of treatment, or a combination of both. CONCLUSION: To ensure prompt, appropriate intervention while avoiding iatrogenic complications, the clinician must evaluate and monitor patients with bipolar disorder for the presence and the development of comorbid psychiatric and medical conditions. Conversely, physicians should have a high index of suspicion for underlying bipolar disorder when evaluating individuals with other psychiatric diagnoses (not just unipolar depression) that often coexist with bipolar disorder, such as alcohol and substance abuse or anxiety disorders. Anticonvulsants and other mood stabilizers may be especially helpful in treating bipolar disorder with significant comorbidity.
PMID: 15673617

31. Respiratory symptoms and mental disorders among youth: results from a prospective, longitudinal study

Goodwin RD, Lewinsohn PM, Seeley JR.
Psychosom Med. 2004 Nov-Dec;66(6):943-9.

OBJECTIVE: To determine the relationship between respiratory symptoms and mental disorders among youth in the community, and to investigate possible mechanisms of these linkages. METHODS: Data were drawn from the Oregon Adolescent Depression Project (n = 1,709), a longitudinal study of adolescents in the community. Multiple logistic regression analyses were used to examine the cross-sectional and longitudinal associations between respiratory symptoms and mental disorders at baseline, and linkages between respiratory symptoms at baseline and the onset of specific mental disorders at follow-up. Additional analyses were performed to examine the strength and specificity of the relationship between respiratory symptoms and mental disorders. The potential roles of hypochondriasis, functional impairment, and cigarette smoking in the associations between respiratory symptoms and mental disorders were investigated. RESULTS: Respiratory symptoms were associated with a significantly increased odds of any mental disorder (odds ratio (OR) = 1.9), specifically any depressive disorder (OR = 1.9), major depression (OR = 1.9), any substance use disorders (OR = 1.6), panic attacks (OR = 3.1), and attention deficit/hyperactivity disorder (ADHD) (OR = 5.8) at baseline. Respiratory symptoms at between 1987 and 1989 (Time 1) were associated with significantly increased risk of the onset of any mental disorder a year later (Time 2) (OR = 2.1). While demographic differences, hypochondriasis, functional impairment, and cigarette smoking contributed to the relationships between respiratory symptoms and mental disorders, these associations persisted after adjusting for these factors. CONCLUSIONS: The results suggest evidence of an association between respiratory symptoms and mental disorders among youth in the community. While demographic differences, hypochondriasis, functional impairment, and cigarette smoking may contribute to the linkage, these factors do not appear to completely explain the association. Future studies that can replicate these findings and include an examination of other possible mechanisms for these patterns of comorbidity, such as shared familial vulnerability or other environmental risk factors (e.g., childhood behavioral risk factors), are needed next.
PMID: 15564362

32. Diagnosing and treating attentional difficulties: a nationwide survey.

McKenzie I, Wurr C.
Arch Dis Child. 2004 Oct;89(10):913-6.

AIMS: To ascertain from paediatricians and child psychiatrists their views regarding the aetiology, assessment, and diagnosis of attentional difficulties in children, and the prescribing of stimulant medication for such difficulties. METHODS: Using a questionnaire devised by the authors, 465 paediatricians and 444 child psychiatrists were surveyed. RESULTS: The overall response rate was 73%. Some 94% of child psychiatrists and 29% of paediatricians routinely dealt with attentional difficulties. Views on aetiology, classification, and diagnosis were varied. More than 60% of both groups were prepared to prescribe stimulant medication without a formal diagnosis being made. Comorbid conduct disorder and the views of other professionals and of parents have an impact on practice. CONCLUSIONS: This survey demonstrates that there is a range of approaches to attentional difficulties by both paediatricians and child psychiatrists.
PMID: 15383433

33. Why bother about clumsiness? The implications of having developmental coordination disorder (DCD).

Gillberg C, Kadesjö B.
Neural Plast. 2003;10(1-2):59-68.

Developmental coordination disorder (DCD) is a common motor problem affecting--even in rather severe form--several percent of school age children. In the past, DCD has usually been called 'clumsy child syndrome' or 'non-cerebral-palsy motor-perception dysfunction'. This disorder is more common in boys than in girls and is very often associated with psychopathology, particularly with attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorders/ autistic-type problems. Conversely, children with ADHD and autism spectrum problems, particularly those given a diagnosis of Asperger syndrome, have a very high rate of comorbid DCD. Psychiatrists appear to be unaware of this type of comorbidity in their young patients. Neurologists, on the other hand, usually pay little attention to the striking behavioral and emotional problems shown by so many of their 'clumsy' patients. A need exists for a much clearer focus on DCD-in child psychiatry and in child neurology-both in research and in clinical practice.
PMID: 14640308

34. Comorbid psychiatric disorders in youth in juvenile detention

Abram KM, Teplin LA, McClelland GM, Dulcan MK.
Arch Gen Psychiatry. 2003 Nov;60(11):1097-108.

OBJECTIVE: To estimate 6-month prevalence of comorbid psychiatric disorders among juvenile detainees by demographic subgroups (sex, race/ethnicity, and age). DESIGN: Epidemiologic study of juvenile detainees. Master's level clinical research interviewers administered the Diagnostic Interview Schedule for Children Version 2.3 to randomly selected detainees. SETTING: A large temporary detention center for juveniles in Cook County, Illinois (which includes Chicago and surrounding suburbs). PARTICIPANTS: Randomly selected, stratified sample of 1829 African American, non-Hispanic white, and Hispanic youth (1172 males, 657 females, aged 10-18 years) arrested and newly detained. MAIN OUTCOME MEASURE: Diagnostic Interview Schedule for Children. RESULTS: Significantly more females (56.5%) than males (45.9%) met criteria for 2 or more of the following disorders: major depressive, dysthymic, manic, psychotic, panic, separation anxiety, overanxious, generalized anxiety, obsessive-compulsive, attention-deficit/hyperactivity, conduct, oppositional defiant, alcohol, marijuana, and other substance; 17.3% of females and 20.4% of males had only one disorder. We also examined types of disorder: affective, anxiety, substance use, and attention-deficit/hyperactivity or behavioral. The odds of having comorbid disorders were higher than expected by chance for most demographic subgroups, except when base rates of disorders were already high or when cell sizes were small. Nearly 14% of females and 11% of males had both a major mental disorder (psychosis, manic episode, or major depressive episode) and a substance use disorder. Compared with participants with no major mental disorder (the residual category), those with a major mental disorder had significantly greater odds (1.8-4.1) of having substance use disorders. Nearly 30% of females and more than 20% of males with substance use disorders had major mental disorders. Rates of some types of comorbidity were higher among non-Hispanic whites and older adolescents. CONCLUSIONS: Comorbid psychiatric disorders are a major health problem among detained youth. We recommend directions for research and discuss how to improve treatment and reduce health disparities in the juvenile justice and mental health systems.
PMID: 14609885

35. Deficits in attention, motor control, and perception: a brief review.

Gillberg C.
Arch Dis Child. 2003 Oct;88(10):904-10.

The concept of DAMP (deficits in attention, motor control, and perception) has been in clinical use in Scandinavia for about 20 years. DAMP is diagnosed on the basis of concomitant attention deficit/hyperactivity disorder and developmental coordination disorder in children who do not have severe learning disability or cerebral palsy. In clinically severe form it affects about 1.5% of the general population of school age children; another few per cent are affected by more moderate variants. Boys are overrepresented; girls are currently probably underdiagnosed. There are many comorbid problems/overlapping conditions, including conduct disorder, depression/anxiety, and academic failure. There is a strong link with autism spectrum disorders in severe DAMP. Familial factors and pre- and perinatal risk factors account for much of the variance. Psychosocial risk factors appear to increase the risk of marked psychiatric abnormality in DAMP. Outcome in early adult age was psychosocially poor in one study in almost 60% of unmedicated cases. There are effective interventions available for many of the problems encountered in DAMP.
PMID: 14500312

36. Parent-child conflict and the comorbidity among childhood externalizing disorders.

Burt SA, Krueger RF, McGue M, Iacono W.
Arch Gen Psychiatry. 2003 May;60(5):505-13.

BACKGROUND: Previous research has suggested that substantial comorbidity exists among childhood externalizing disorders, specifically attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). Moreover, parent-child conflict predicts each of these disorders. Our goals were to determine whether parent-child conflict was associated with the comorbidity among ADHD, CD, and ODD, and to explicitly examine the etiology of this association via a genetically informative design. METHODS: We compared the fit of the following 2 biometric models: the 2-factor common-pathway model, which examined genetic and environmental contributions to the relationship between conflict and the covariation among the 3 disorders, and the Cholesky model, which examined the relationship between conflict and each disorder individually. The sample consisted of 808 same-sex 11-year-old twin pairs from the Minnesota Twin Family Study, a population-based sample of Minnesota twins and their families. Main outcome measures included symptom counts for ADHD, CD, and ODD, obtained from structured interviews administered to twins and their mothers. Parent-child conflict was assessed via mother and twin reports of the Parental Environment Questionnaire. RESULTS: The 2-factor model provided a better fit to the data. These results indicated that conflict accounted for 33% of the covariation among the disorders, via genetic and environmental factors. CONCLUSIONS: Parent-child conflict appears to act as a common vulnerability that increases risk for multiple childhood disorders. Furthermore, this association is mediated via common genetic and environmental factors. These findings support the idea that the comorbidity among these disorders partially reflects core psychopathological processes in the family environment that link putatively separate psychiatric disorders.
PMID: 12742872

37. Psychiatric disorders in youth in juvenile detention

Teplin LA, Abram KM, McClelland GM, Dulcan MK, Mericle AA.
Arch Gen Psychiatry. 2002 Dec;59(12):1133-43.

BACKGROUND: Given the growth of juvenile detainee populations, epidemiologic data on their psychiatric disorders are increasingly important. Yet, there are few empirical studies. Until we have better epidemiologic data, we cannot know how best to use the system's scarce mental health resources. METHODS: Using the Diagnostic Interview Schedule for Children version 2.3, interviewers assessed a randomly selected, stratified sample of 1829 African American, non-Hispanic white, and Hispanic youth (1172 males, 657 females, ages 10-18 years) who were arrested and detained in Cook County, Illinois (which includes Chicago and surrounding suburbs). We present 6-month prevalence estimates by demographic subgroups (sex, race/ethnicity, and age) for the following disorders: affective disorders (major depressive episode, dysthymia, manic episode), anxiety (panic, separation anxiety, overanxious, generalized anxiety, and obsessive-compulsive disorders), psychosis, attention-deficit/hyperactivity disorder, disruptive behavior disorders (oppositional defiant disorder, conduct disorder), and substance use disorders (alcohol and other drugs). RESULTS: Nearly two thirds of males and nearly three quarters of females met diagnostic criteria for one or more psychiatric disorders. Excluding conduct disorder (common among detained youth), nearly 60% of males and more than two thirds of females met diagnostic criteria and had diagnosis-specific impairment for one or more psychiatric disorders. Half of males and almost half of females had a substance use disorder, and more than 40% of males and females met criteria for disruptive behavior disorders. Affective disorders were also prevalent, especially among females; more than 20% of females met criteria for a major depressive episode. Rates of many disorders were higher among females, non-Hispanic whites, and older adolescents. CONCLUSIONS: These results suggest substantial psychiatric morbidity among juvenile detainees. Youth with psychiatric disorders pose a challenge for the juvenile justice system and, after their release, for the larger mental health system.
PMID: 12470130

38. Correlates of ADHD among children in pediatric and psychiatric clinics

Busch B et al.
Psychiatr Serv. 2002 Sep;53(9):1103-11.

OBJECTIVE: Conventional wisdom among pediatricians has been that children with attention-deficit hyperactivity disorder (ADHD) who receive their diagnosis and are managed in the primary care setting have fewer comorbid psychiatric disorders and milder impairments than those seen in psychiatric clinics. The authors sought to determine whether comorbidity and clinical correlates of ADHD differ among children in these two settings. METHODS: A case-control study design was used. Participants were 522 children and adolescents of both sexes, six to 18 years of age, with (N=280) and without (N=242) ADHD. Participants were drawn from pediatric and psychiatric clinics in a tertiary care hospital and a health maintenance organization in a large metropolitan area. Assessments were conducted with standardized measures of psychiatric, cognitive, social, academic, and family function. RESULTS: The number, type, clusters, and age at onset of ADHD symptoms were nearly identical for youths at pediatric and psychiatric ascertainment sources. Regardless of source, participants with ADHD were significantly more likely than controls to have a higher prevalence of mood disorders, other disruptive behavior, anxiety disorders, and substance use disorders. Significant impairments of intellectual, academic, interpersonal, and family functioning did not differ between ascertainment sources. CONCLUSIONS: Children with ADHD from both psychiatric and pediatric practices have prototypical symptoms of the disorder; high levels of comorbidity with mood, anxiety, and disruptive behavior disorders; and impairments in cognitive, interpersonal, and academic function that do not differ by ascertainment source. These findings suggest that children cared for in pediatric practice have similar levels of comorbidity and dysfunction as psychiatrically referred youth.
PMID: 12221308

39. Psychiatric comorbidity, family dysfunction, and social impairment in referred youth with oppositional defiant disorder

Greene RW, Biederman J, Zerwas S, Monuteaux MC, Goring JC, Faraone SV.
Am J Psychiatry. 2002 Jul;159(7):1214-24.

OBJECTIVE: The authors sought to achieve an improved understanding of the diagnosis of oppositional defiant disorder independent of its association with conduct disorder. METHOD: Family interactions, social functioning, and psychiatric comorbidity were compared in clinically referred male and female subjects with oppositional defiant disorder alone (N=643) or with comorbid conduct disorder (N=262) and a psychiatric comparison group with neither oppositional defiant disorder nor conduct disorder (N=695). RESULTS: Oppositional defiant disorder youth with or without conduct disorder were found to have significantly higher rates of comorbid psychiatric disorders and significantly greater family and social dysfunction relative to psychiatric comparison subjects. Differences between subjects with oppositional defiant disorder alone and those with comorbid conduct disorder were seen primarily in rates of mood disorders and social impairment. Oppositional defiant disorder was a significant correlate of adverse family and social outcomes when comorbid disorders (including conduct disorder) were controlled. CONCLUSIONS: These results support the validity of the oppositional defiant disorder diagnosis as a meaningful clinical entity independent of conduct disorder and highlight the extremely detrimental effects of oppositional defiant disorder on multiple domains of functioning in children and adolescents.
PMID: 12091202

40. Influence of gender on attention deficit hyperactivity disorder in children referred to a psychiatric clinic

Biederman J et al.
Am J Psychiatry. 2002 Jan;159(1):36-42.

OBJECTIVE: The substantial discrepancy in the male-to-female ratio between clinic-referred (10 to 1) and community (3 to 1) samples of children with attention deficit hyperactivity disorder (ADHD) suggests that gender differences may be operant in the phenotypic expression of ADHD. In this study the authors systematically examined the impact of gender on the clinical features of ADHD in a group of children referred to a clinic. METHOD: The study included 140 boys and 140 girls with ADHD and 120 boys and 122 girls without ADHD as comparison subjects. All subjects were systematically assessed with structured diagnostic interviews and neuropsychological batteries for subtypes of ADHD as well as emotional, school, intellectual, interpersonal, and family functioning. RESULTS: Girls with ADHD were more likely than boys to have the predominantly inattentive type of ADHD, less likely to have a learning disability, and less likely to manifest problems in school or in their spare time. In addition, girls with ADHD were at less risk for comorbid major depression, conduct disorder, and oppositional defiant disorder than boys with ADHD. A statistically significant gender-by-ADHD interaction was identified for comorbid substance use disorders as well. CONCLUSIONS: The lower likelihood for girls to manifest psychiatric, cognitive, and functional impairment than boys could result in gender-based referral bias unfavorable to girls with ADHD.
PMID: 11772687

41. Separating attention deficit hyperactivity disorder and learning disabilities in girls: a familial risk analysis

Doyle AE, Faraone SV, DuPre EP, Biederman J.
Am J Psychiatry. 2001 Oct;158(10):1666-72.

OBJECTIVE: Familial risk analysis was used to clarify the relationship in girls between attention deficit hyperactivity disorder (ADHD) and learning disabilities in either mathematics or reading. METHOD: The authors assessed the presence of ADHD and learning disabilities in 679 first-degree relatives of three groups of index children: girls with ADHD and a comorbid learning disability, girls with ADHD but no learning disabilities, and a comparison group of girls without ADHD. RESULTS: The risk for ADHD was similarly higher in families of ADHD probands with and without learning disabilities; both groups had significantly higher rates of ADHD than did families of the comparison girls. In contrast, only among relatives of ADHD probands with a learning disability was there a higher risk for learning disabilities. A strong (although statistically nonsignificant) difference emerged that suggested at least some degree of cosegregation of ADHD and learning disabilities in family members. There was no evidence of nonrandom mating between spouses with ADHD and learning disabilities. CONCLUSIONS: These results extend previously reported findings regarding the relationship of ADHD and learning disabilities to female subjects and raise the possibility that, in girls, the relationship between ADHD and learning disabilities is due to shared familial risk factors.
PMID: 11579000

42. Examining the comorbidity of ADHD-related behaviours and conduct problems using a twin study design

Thapar A, Harrington R, McGuffin P.
Br J Psychiatry. 2001 Sep;179:224-9.

BACKGROUND: Although attention-deficit hyperactivity disorder (ADHD) and conduct disorder (CD) frequently co-occur, the underlying mechanisms for this comorbidity are not well understood. AIMS: To examine whether ADHD and conduct problems share common risk factors and whether ADHD+CD is a more heritable variant of ADHD. METHOD: Questionnaires were sent to 2846 families. Parent-rated data were obtained for 2082 twin pairs and analysed using bivariate genetic analysis and a liability threshold model approach. RESULTS: The overlap of ADHD and conduct problems was explained by common genetic and non-shared environmental factors influencing both categories. Nevertheless, the two categories appeared to be partly distinct in that additional environmental factors influenced conduct problems. It appeared that ADHD+CD was a genetically more severe variant of ADHD. CONCLUSIONS: Conduct problems and ADHD share a common genetic aetiology; ADHD+CD appears to be a more severe subtype in terms of genetic loading as well as clinical severity.
PMID: 11532799

43. Attention deficit hyperactivity disorder

Guevara JP, Stein MT.
West J Med. 2001 Sep;175(3):189-93.
PMID: 11527851

44. Diagnosis of attention-deficit/hyperactivity disorder and use of psychotropic medication in very young children

Rappley MD, Mullan PB, Alvarez FJ, Eneli IU, Wang J, Gardiner JC.
Arch Pediatr Adolesc Med. 1999 Oct;153(10):1039-45.

CONTEXT: Increases in diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) have elicited public and professional concern. Research suggests that this trend warrants the inclusion of previously underdiagnosed children and adults. It is not clear whether this trend includes young children. OBJECTIVE: To identify patterns of diagnosis and treatment of ADHD in very young children over time. DESIGN: Descriptive study of Michigan Medicaid claims data. PATIENTS: Inclusion criteria included recorded ADHD diagnosis, continuous Medicaid eligibility during a 15-month period, and age 3 years or younger at the first date of service. MAIN OUTCOME MEASURES: Diagnoses of ADHD, conditions commonly comorbid with ADHD, other chronic health conditions, and injuries; treatments such as psychological services and psychotropic medication; and the number of ambulatory visits. RESULTS: We identified 223 children aged 3 years or younger diagnosed with ADHD. Many had conditions commonly comorbid with ADHD (44%), other chronic health conditions (41%), and injuries (40%). More than half received psychotropic medication (57%); fewer received psychological services (27%). Twenty-two different psychotropic medications were used. Patterns included more than 1 psychotropic medication (46%) in 30 combinations of simultaneous use and 44 combinations of sequential use. The mean number of ambulatory visits was 18. CONCLUSIONS: Children aged 3 years or younger had ADHD diagnosed and received markedly variable psychotropic medication regimens. Little information is available to guide these practices. The presence of comorbid conditions and injuries attests to these children's vulnerability. Resources must be identified that will enable physicians to better respond to the compelling needs of these children and their families.
PMID: 10520611

45. Psychiatric disorders and behavioral characteristics of pediatric patients with both epilepsy and attention-deficit hyperactivity disorder

Gonzalez-Heydrich J et al.
Epilepsy Behav. 2007 May;10(3):384-8.

OBJECTIVE: Attention-deficit hyperactivity disorder (ADHD) coexisting with epilepsy is poorly understood; thus, we compared the clinical correlates and psychiatric comorbid conditions of 36 children with epilepsy and ADHD aged 6 to 17 years enrolled in an ADHD treatment trial, with those reported in the literature on children with ADHD without epilepsy. METHODS: Measures included the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (KSADS), the Wechsler Abbreviated Scale of Intelligence (WASI), and the Scales for Independent Behavior-Revised (SIB-R). RESULTS: Mean IQ was 86+/-19, and SIB-R Standard Score was 72+/-26. The ADHD-Combined subtype, composed of both inattentive and hyperactive symptoms, was most frequent (58%). Sixty-one percent exhibited a comorbid disorder, including anxiety disorders (36%) and oppositional defiant disorder (31%). CONCLUSIONS: Comorbidity in ADHD with epilepsy is similar to that in ADHD without epilepsy reported in the literature. These preliminary data argue that the pathophysiology of ADHD has common components in both populations.
PMID: 17368109

46. Attention deficit and hyperactivity disorder, methylphenidate, and epilepsy

Tan M, Appleton R.
Arch Dis Child. 2005 Jan;90(1):57-9.

Attention deficit hyperactivity disorder (ADHD) is characterised by inattention, impulsivity, and hyperactivity. The DSM-IV diagnosis of ADHD requires the presence of six of nine items or features that must have been present for at least six months, to have had an onset before 7 years of age, and to have resulted in significant distress or impairment.1 In the general population, the prevalence of ADHD is approximately 5%.2 There is a high co-morbidity of epilepsy and attentional and behavioural problems,3,4 including ADHD, and it has been estimated that at least 20% of patients with epilepsy may present with features of ADHD.5.
PMID: 15613514

47. Optimizing therapy of seizures in children and adolescents with ADHD

Aldenkamp AP, Arzimanoglou A, Reijs R, Van Mil S.
Neurology. 2006 Dec 26;67(12 Suppl 4):S49-51.

Attention deficit hyperactivity disorder (ADHD) can coexist with epilepsy and the prevalence of ADHD in epilepsy is three to five times greater than normal. This may be an effect of the epilepsy (particularly as a secondary symptom of subtle seizures) or of the antiepileptic treatment. There is an ongoing debate about the nature of ADHD in epilepsy and especially whether successive comorbidity exists (i.e., the possibility that epilepsy lowers the threshold for developing ADHD). Treatment of comorbid ADHD may be difficult. Methylphenidate is still the treatment of choice for the condition and, although it has been shown that neither methylphenidate nor other psychostimulants provoke seizures, there is still a possibility that seizure frequency may increase in children with active epilepsy.
PMID: 17190923

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