The 6 most important ADHD comorbidities

These are the psychological disorders that most overlap with ADHD.

Those living with a diagnosis of attention deficit hyperactivity disorder (ADHD) face, every day of their lives, significant obstacles in achieving their most important 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. From a very young age, they can be labeled as agitated or even violent, which conditions the way they live this age period.

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

In the present article we will address some of the comorbidities of ADHD.. All of them are important, as they are linked to a worsening of the symptomatology and/or its prognosis and evolution. Let us enter, without further ado, in such a relevant issue.

Attention Deficit Hyperactivity Disorder (ADHD)

ADHD is a neurodevelopmental disorder associated with three different symptomsThese are: impulsivity (problems in inhibiting impulses or delaying incentives), inattention (difficulty in maintaining "focus" for the necessary time on a task being performed) and motor hyperactivity (feeling of urgency and inability to remain in a state of stillness in contexts in which this should be done). There are different profiles of ADHD, since each person suffering 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 according to the DSM-5 manual, with an expression that very often begins before the age of five and exceptionally debuts after the age of seven. The resonances on cognition, especially in executive function (planning or inhibitory control), imply notorious consequences on several areas of daily functioning. Therefore, many of these have been used to explain the comorbidities that the literature has detected for this same group of patients.

Comorbidity is understood as the presence of two or more clinical entities (including ADHD) simultaneously in a single individual (child or adult), in such a way that 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 traced between them. The result cannot be calculated through a simple sum of the diagnoses, but rather there is an interaction between them from which a unique manifestation emerges for each of the individuals who may present it. This is because these comorbid disorders are mixed with the personality and character dimensions, resulting in a profound psychopathological idiosyncrasy.

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

Attention Deficit Hyperactivity Disorder Comorbidities

We proceed to detail the six disorders that most frequently occur with ADHD. Although at the beginning a special emphasis was placed on externalizing disorders (disruptive behaviors), nowadays the importance of internalizing disorders (e.g. major depression) for the balanced development of the person with this clinical picture is also beginning to be considered.

Major depression

Depression is a disorder characterized by a deep sadness and a great difficulty to experience pleasure.. In the case of children and adolescents, it is sometimes expressed as irritability (and is confused with behavioral disturbances). The scientific community is becoming increasingly aware of the possibility that such a mood problem may be present in those diagnosed with ADHD, very often as the emotional result of existing limitations in adapting to school or in building relationships with peers.

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 depression.This increases their subjective level of stress and exacerbates the underlying cognitive problems. These conditions have a much earlier onset than that observed in the general population, and require the design of interventions of greater intensity and duration. The high concurrence of both conditions was the definitive incentive for the research community to define the common aspects that could explain and predict it.

After multiple studies on this issue, 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 the excessive emphasis on past negative experiences or ominous expectations for the future. Among all the characteristics associated with such a relevant shared factor, intolerance to frustration stands out as the one with the greatest 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 in delaying rewards or tolerating the existence of obstacles that prevent their immediate and unconditional achievement. This circumstance would precipitate the emergence of a recurrent sense of failure, the dissolution of any motivation to achieve goals and the solid belief that one is different and/or inappropriate. All this can be accentuated when, in addition, one lives every day with constant criticism.

2. Anxiety disorders

Anxiety disorders are also very frequent in ADHD. Studies on this issue conclude that between 28% and 33% of people with this diagnosis meet the criteria for some anxiety problem, and especially when they reach the age of 18.especially when they reach adolescence. It is also at this point that differences begin to emerge between boys and girls in terms of the risk of suffering from them, being much more common in girls than in boys. When comparing subjects with and without ADHD, it is noted that in the first case these disorders emerge at earlier ages and are more lasting.

Children with ADHD show higher levels of social anxiety than those without ADHD, and are more likely to report acute panic attacks.and are more likely to report acute panic attacks and specific phobias. The latter may be formed by developmentally 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 describing a higher prevalence of generalized anxiety disorder in this population, characterized by constant/unavoidable worries about a broad constellation of everyday issues.

It is known that This comorbidity is known to be more common in those with mixed ADHDthat is, with hyperactivity/inattention symptoms. However, it is believed that attentional deficits are more intimately related to anxiety than any other of its forms of expression. Nevertheless, anxiety accentuates impulsivity and executive function alterations to the same extent, aggravating any difficulty (academic, occupational, etc.) that one may be going through.

3. Bipolar disorder

Bipolar disorder in childhood and ADHD overlap significantly at the clinical level, so much so that they are often confused and indistinguishably mixed. Thus, both both present with low frustration tolerance, high irritability and even outbursts, which do not fit the that do not fit with the objective characteristics of the event that triggers them. It is also possible that in both there is difficulty in delaying rewards and "fluctuations" (more or less marked) of mood. Because treatment is different in each case, you should identify the particular disorder you have or whether there is an underlying comorbidity.

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

Finally, it has also been reported that about half of the infants with bipolar disorder present inappropriate sexual behaviors, that is, behaviors that do not correspond to their age and that are displayed in contexts in which they are disruptive (e.g. masturbation in public places). All this without there having been a history of abuse (a context in which these habits can arise in a common way).

In addition, they also They also express with some frequency that they do not need to sleep, something that must be distinguished fromThis should 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 adolescence is reached.The risk of substance abuse increases fivefold. The research carried out on this essential issue yields 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, what is really true is that no clear pattern can be distinguished, with all types of consumption being described (most of the time being an addiction to several substances at the same time).

A very relevant percentage of adolescents showing ADHD/addiction showed problematic behavior prior to this stage, which may include discreet thefts or other activities that infringe on the rights of others. Likewise, there is evidence of an early debut in recreational use (often before the age of fifteen) together with a substantially higher presence of antisocial personality traits (50% in adolescents with ADHD and addiction and 25% in those with ADHD alone).

There is evidence that the presence of ADHD symptoms has a negative impact on the prognosis of addiction, and that on the other hand, the use of ADHD is associated with a higher incidence of addiction.On the other hand, substance use alters the effectiveness of the drugs that are usually administered to regulate its symptoms (especially central nervous system stimulants). 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.

Finally, work with the family is always essential, work with the family is always essentialaimed 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 had been played up to that moment. 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. Conduct disorders

Conduct disorders are common in children with ADHD. These are acts that are harmful to other people or to the child him/herself, and are related to a high level of conflict in the family and school environment. Some examples of this could be bullying, arguments with parents that include scenes of physical/verbal violence, petty theft and temper tantrums whose purpose is to extract a secondary benefit. All 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 in conventional ADHD. And it is that in general the symptoms of inattention, impulsivity and hyperactivity are much more intense; and they end upand end up torpedoing the child's efforts to overcome the historical milestones associated with each stage of development (which isolates him/her from peer groups with prosocial tendencies and segregates him/her in marginal groups where dissocial behaviors acquire a normative value and reinforcing power).

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 one or both of these parents to suffer from serious mental pathologies (including antisocial disorder or chemical and non-chemical addictions). This situation also increases the risk of the minor's involvement in drug use, aggravating his or her problems, as discussed 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 up to 50% of adolescents who attempt or succeed in suicide have some 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 with a diagnosis of ADHD are more likely to engage in suicidal behavior, to present self-injurious ideation and even to cause themselves injuries of varying degrees of severity.

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 attempted to take their own lives at least once, and 5% die precisely because of it. and that 5% die precisely because of it. The risk increases when living with major depression, a behavioral problem or substance dependence, and also if the patient is male. This 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 presented by these patients, especially in areas such as attention and behavioral inhibition, are associated with an increased risk of suicidal behavior. To such an extent 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.