The 6 most important ADHD comorbidities

Those living with a diagnosis of attention deficit hyperactivity disorder (ADHD) face, every day of their lives, notable obstacles in the achievement of their personal goals more relevant.

And not only because of the impact of alterations in executive functions, such as attention and / or inhibition behavioral, but also by the "social frictions" in which its particular expression is implied. clinic. And it is that from a very young age they can be labeled as agitated or even violent, which determines the way in which they live this age period.

The literature on ADHD suggests that, beyond the limitations that this neurodevelopmental disorder imposes, the affective consequences related to difficulties in achieving school goals or in meeting all the demands of a job job.

In this article we will address some of the comorbidities of ADHD. All of them are important, since they are linked to a worsening of symptoms and / or their prognosis and evolution. Let us enter, without further ado, into such an important issue.

• Related article: "Types of ADHD (characteristics, causes and symptoms)"

Attention deficit disorder and hyperactivity

ADHD is a neurodevelopmental disorder to which three different symptoms are associatednamely: impulsivity (problems inhibiting impulses or delaying incentives), inattention (difficulty maintaining "focus" for the necessary time on a task that is being performed) and motor hyperactivity (feeling of urgency and inability to remain in a state of stillness in contexts where you should to be made). There are different profiles of ADHD, since each of the people who suffers from it reports very different symptoms (emphasis on inattention or hyperactivity, or even a mixture of both).

It is estimated that a percentage between 3% and 10% of the child population presents symptoms compatible with this diagnosis following the DSM-5 manual, with an expression that very often begins before the age of five and exceptionally begins after the age of five. seven. The resonances on cognition, especially in executive function (planning or inhibitory control), imply notorious consequences on various areas of 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 understood to be the presence of two or more clinical entities (including ADHD) simultaneously in a single individual (child or adult), in such a way that a synergistic relationship is drawn between them. The result cannot be calculated through a simple sum of the diagnoses, but rather a interaction between them from which a unique manifestation emerges for each of the people who could introduce. And this is so because these comorbid disorders are mixed with the personality and character dimensions, resulting from this process a profound psychopathological idiosyncrasy.

In patients with ADHD, comorbidity is the rule, and not an exception, so the presence of all the disorders that can be seen must be taken into account. They will detail from the very beginning of the therapeutic relationship (initial interview with the parents and the infant, definition of evaluation strategies, etc.). It is known that, in addition, comorbidity can darken the prognosis and accentuate the obstacles that the family will face deal with as time passes, given that up to 50% of cases extend beyond the adolescence.

• Related article: "Neurobiology of ADHD: the brain bases of this disorder"

Comorbidities of Attention Deficit Hyperactivity Disorder

We proceed to detail the six disorders that most frequently concur with ADHD. Although at first a very special emphasis was placed on externalizing disorders (disruptive behaviors), today it is beginning to also consider the importance of internalizers (major depression, for example) for the balanced development of the person with this condition clinical.

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 a mental problem may occur in those who have a diagnosis of ADHD, most often as the emotional result of existing limitations in adjusting to school or in forging relationships with equal.

In any case, it is estimated that between 6% and 9% of children and adolescents with ADHD have a comorbid diagnosis of depression, which increases their subjective level of stress and exacerbates the underlying cognitive problems. These are conditions that debut much earlier than what is observed in the general population, and that require the design of interventions of more intensity and duration. The high concurrence of both was the definitive spur for the research community to set out to define the common aspects that could explain and predict it.

After multiple studies on this matter, it was concluded that the common axis was emotional dysregulation; understood as the presence of excessive affective reactions in contrast to the triggering event, the great lability of internal states and overemphasis on negative past experiences or ominous expectations for the future. Among all the characteristics associated with such a relevant shared factor, frustration intolerance stands out as the one with greater explanatory and predictive power.

It has been described that up to 72% of children with ADHD present this trait, which is expressed as a relevant Difficulty delaying the reward or tolerating the existence of obstacles that prevent its immediate achievement and unconditional. This circumstance would precipitate the emergence of a recurring feeling of failure, the dissolution of all motivation to achieve goals and the solid belief that one is different and / or inappropriate. All this can be accentuated when, in addition, there is constant criticism every day.

• You may be interested: "Major depression: symptoms, causes and treatment"

2. Anxiety disorders

Anxiety disorders are also very common in ADHD. Studies on this 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 point that differences between boys and girls in terms of the risk of suffering from them begin to be noticed, being much more common in them than in them. When comparing subjects with and without ADHD, it is noted that in the first case these disorders emerge at an earlier age and are more durable.

Children with ADHD show higher levels of social anxiety than those without it, and they are more likely to refer to acute panic attacks and specific phobias. The latter may be formed by evolutionarily normal fears that persist despite the passage of time, which accentuates them and accumulates them with those that arise during later periods. There are also studies that describe a higher prevalence of generalized anxiety disorder in this population, characterized by constant / unavoidable concerns around a vast constellation of issues everyday.

It's known that this comorbidity is more common in those with mixed ADHD, that is, with symptoms of hyperactivity / inattention. However, it is believed that attention deficits are related to anxiety in a more intimate way than any other of its forms of expression. Despite this, anxiety accentuates impulsivity and impaired executive function in the same measure, aggravating all difficulties (academic, work, etc.) that could be going through.

3. Bipolar disorder

The Bipolar disorder in childhood and ADHD overlap in an important way at the clinical level, in such a way that they are often confused and mixed in an indistinguishable way. Thus both they have a low tolerance for frustration, high irritability and even outbursts that do not fit with the objective characteristics of the fact that triggers them. It is also possible that both have difficulty delaying rewards and "fluctuations" (more or less pronounced) in mood. Because the treatment is different in each case, the particular disorder suffered or if there is a basic comorbidity must be identified.

There are some differences between bipolar disorder and ADHD that should be considered at the time of evaluation. To distinguish the one from the other, it is key to consider the following: in bipolar disorder there is a long family history of this same clinical picture, there are periods of great expansiveness of the mood, irritable affectivity stands out compared to depressive, emotional swings are more frequent / severe and there is a tendency to grandiosity in the way you think about yourself same.

Finally, it has also been described that more or less half of infants with bipolarity present inappropriate sexual behaviors, or whatever the same, that they do not correspond to their age and that are deployed in contexts in which they are disruptive (masturbation in public places, e.g.). All this without there having been a history of abuse (a context in which these habits can arise in a common way).

Besides, also express with some frequency that they do not require sleep, something that must be distinguished from the reluctance to go to bed typical of ADHD.

4. Addictions

Addictions are also a very important problem in ADHD, especially when it reaches adolescence, where the danger of substance abuse is five times higher. The investigations carried out on this essential issue show figures of between 10 and 24% of comorbid dependence, reaching maximum prevalences of 52% in some of the studies. Although there is a belief that there is a kind of preference for stimulant drugs, the truth is that it is not distinguishes a clear pattern, describing all types of consumption (most of the time being an addiction to various substances to the time).

A very relevant percentage of adolescents who show ADHD / addiction previously showed problematic behavior at this stage, which may include discreet theft or other activities that violate the rights of the the rest. Likewise, there is evidence of an early debut in recreational use (often before the age of fifteen) together with a substantially greater presence of antisocial personality traits (50% in adolescents with ADHD and addiction and 25% in those with only ADHD).

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 that usually be administered in order to regulate your symptoms (especially stimulants of the nervous system central). It should not be forgotten, on the other hand, that the therapeutic approach with such drugs requires the closest possible follow-up in cases of addiction, to avoid their inappropriate use.

By last, working with the family is always essential, aimed at promoting tools that minimize the risk of relapse and preserve relational balance. All drug use is a difficult situation at the level of the social group, and requires adjusting the different roles that they had been performing up to now. On the other hand, at the systemic level there is what appears to be an indissoluble functional and bidirectional connection: ADHD is more common in families where there is addiction and addiction is more common in families where there is ADHD.

5. Behavioral disorders

Conduct disorders are common in children with ADHD. These are acts that cause harm to other people or to the child himself, and which are related to a high level of conflict in the family and at school. Some examples of this can be bullying, arguments with parents that include scenes of physical / verbal violence, petty theft and tantrums whose purpose is to extract a profit secondary. All of this would definitely translate into aggressive, defiant and impulsive behaviors.

When ADHD presents with 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 the historical milestones that are associated with each stage of development (which isolates him from the groups of equals with prosocial tendencies and segregates it into marginal groups where dissocial behaviors acquire a normative value and power reinforcing).

The family history of such a case of comorbidity is characterized by poor parenting, poor supervision of the infant'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 either or both of these parents to suffer from serious mental illness (including antisocial disorder or chemical and non-chemical addictions). This situation also increases the risk that the minor incurs in the use of drugs, worsening all his problems, as seen in a previous section.

6. Suicide

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 moment of the suicidal act as a reference. It is known that patients diagnosed with ADHD are more likely to engage in behaviors suicidal, of presenting a self-destructive ideation and even of injuring themselves of different consideration.

The literature on this issue is consistent in pointing to adolescence and adulthood as the periods of greatest vulnerability, to the point that 10% of adults with ADHD have tried to kill themselves at least once and that 5% die precisely from this cause. The risk increases when you live with major depression, a behavior problem, or a substance dependence; and also in the case that the patient is male. That is why, during the treatment that is articulated for subjects with ADHD and some comorbidity, this possibility must be kept in mind.

The cognitive alterations that these patients present, especially in areas such as attention and behavioral inhibition, are associated with a greater risk of suicidal behavior. This is so much the case that many studies on the epidemiology of suicide highlight ADHD as a risk factor for this important health and social problem.

Bibliographic references:

• Klassen, L., Katzman, M. and Chokka, P. (2009). Adult ADHD and its comorbidities, with a focus on bipolar disorder. Journal of Affective Disorders, 124, 1-8.
• Sherman, J. and Tarnow, J. (2013). What are common comorbidities in ADHD? Psychiatric Times, 30, 47-59.