Those who live with a diagnosis of attention deficit hyperactivity disorder (ADHD) face, every day of their life, significant obstacles in achieving their most relevant personal goals.
And not only because of the impact of alterations in executive functions, such as attention and / or behavioral inhibition, but also because of the “social friction” in which their particular clinical expression is involved. And from a very young age they can be labeled as agitated or even violent, which determines the way they live this period of age.
The ADHD literature suggests that, beyond the limitations that this neurodevelopmental disorder imposes, the affective consequences related to difficulties in achieving school goals or to satisfy all the demands of a job also contribute.
In this article we will address some of the ADHD comorbidities . All of them are important, since they are linked to a worsening of the symptomatology and / or its prognosis and its evolution. Let us enter, without further ado, in such a relevant matter.
- Related article: ” Types of ADHD (characteristics, causes and symptoms)“
Attention deficit disorder and hyperactivity
ADHD is a neurodevelopmental disorder that is associated with three different symptoms , namely: impulsivity (problems to inhibit impulses or delay incentives), inattention (difficulty in maintaining the “focus” for the necessary time on a task that is is performing) and motor hyperactivity (feeling of urgency and inability to remain in a state of stillness in contexts in which it should be done). There are different profiles of ADHD, since each person who suffers from it refers to 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 starts before five years and exceptionally debuts after the seven. The resonances on cognition, especially in executive function (planning or inhibitory control), have noticeable consequences on various areas of daily functioning. Therefore, many of those 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), so that a synergistic relationship is drawn between them. The result cannot be calculated through a simple sum of the diagnoses, but rather an interaction occurs between them from which a unique manifestation emerges for each of the people who could present it. And this is because these comorbid disorders are mixed with personality dimensions and character, resulting in this process a deep psychopathological idiosyncrasy.
In patients with ADHD, comorbidity is the rule, and not an exception, so the presence of all disorders that will be detailed from the very beginning of the therapeutic relationship (initial interview with parents and parents) must be taken into account. infant, definition of evaluation strategies, etc.). It is known that, in addition, comorbidity can overshadow 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.
- 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 initially a very special emphasis was placed on externalizing disorders (disruptive behaviors), the importance of internalizing (major depression, eg) for the balanced development of the person with this clinical picture is also beginning to be considered.
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 alterations). The scientific community is increasingly sensitized to the possibility that such a mood problem arises in those who have a diagnosis of ADHD, very often as the emotional result of the existing limitations to adapt to school or to forge 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 stress and exacerbates the underlying cognitive problem. These are tables that debut much sooner than what was observed in the general population, and that require designing interventions of more intensity and duration. The high attendance of both meant the definitive incentive for the research community to set out 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 detonating event, the great lability of the 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, frustration intolerance rises like that with greater explanatory and predictive power .
It has been described that up to 72% of children with ADHD have this trait, which is expressed as a significant difficulty in delaying the reward or tolerating the existence of obstacles that impede their immediate and unconditional achievement. This circumstance would precipitate the emergence of a recurring sense of failure, the dissolution of all motivation for the achievement of goals and the solid belief that it is different and / or inappropriate. All this can be accentuated when, in addition, each day coexists with constant criticism.
- You may be interested: ” Major depression: symptoms, causes and treatment“
2. Anxiety disorders
Anxiety disorders are also very common in ADHD. Studies on this issue conclude that between 28% and 33% of people with this diagnosis meet the criteria for an anxious problem , especially when they reach adolescence. It is also at this point that differences between boys and girls begin to be noticed in terms of the risk of suffering them, 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 earlier ages and are more durable.
Children with ADHD show higher levels of social anxiety than those without it , and are more likely to report 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 describing a higher prevalence of generalized anxiety disorder in this population, characterized by constant / unavoidable concerns around an extensive constellation of everyday affairs.
It is 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 form of expression. Despite this, anxiety accentuates the impulsiveness and alterations of the executive function to the same extent, aggravating all difficulties (academic, labor, etc.) that could be going through.
3. Bipolar disorder
The bipolar disorder in children and ADHD significantly overlap clinically, in such wise that often are confused and mixed indistinguishably. Thus, both have low tolerance for frustration, high irritability and even outbursts that do not fit the objective characteristics of the fact that triggers them. It is also possible that the two concur difficulty in delaying rewards and “fluctuations” (more or less pronounced) of mood. Because the treatment is different in each case, the particular disorder that is suffered must be identified or if there is a basic 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 essential to take into account the following: in the bipolar disorder there is a wide family history of this same clinical picture, periods of great expansiveness of the mood concur, the irritable affect against the depressive one stands out, the emotional turns are more frequent / serious and there is a tendency to greatness in the way you think about yourself.
Finally, it has also been described that more or less half of infants with bipolarity exhibit inappropriate sexual behavior, or what is the same, that they do not correspond to their age and that they are deployed in contexts in which they are disruptive (masturbation in public places, eg). All this without a history of abuse (context in which these habits can arise in a common way).
In addition, they also express with some frequency that they do not require sleep , something that must be distinguished from the reluctance to go to the ADHD’s own bed.
Addictions are also a very important problem in ADHD, especially when you reach adolescence , where the danger of substance abuse is quintupled. The investigations carried out on such an essential issue show figures of between 10 and 24% of comorbid dependence, reaching a maximum prevalence of 52% in some of the works. Although there is a belief that there is a kind of preference for stimulant drugs, the truth is that there is no clear pattern, describing all types of consumption (most often being an addiction to several substances at once).
A very significant percentage of adolescents who show ADHD / addiction showed problematic behavior prior to this stage, among which discrete thefts or other activities that threaten the rights of others may be included. Likewise, there is evidence of an early debut in recreational consumption (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 who only have ADHD).
There is evidence that the presence of ADHD symptoms negatively affects the prognosis of addiction , and that the use of substances on the other hand alters the effectiveness of the drugs that are usually administered in order to regulate their symptoms (on all central nervous system stimulants). It should not be forgotten, on the other hand, that the therapeutic approach with such medications requires the closest possible follow-up in cases of addiction, to avoid improper use of them.
Finally, 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 it requires adjusting the different roles that until now had been playing. On the other hand, at the systemic level there is what seems 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
Behavioral disorders are common in children with ADHD. These are acts that are harmful to other people or to the child himself, and that are related to a high level of conflict in the family and school environment. Some examples of this may be bullying, discussions with parents that include scenes of physical / verbal violence, small thefts and tantrums whose purpose is to extract a secondary benefit. All this would definitely translate into aggressive, challenging and impulsive behaviors.
When ADHD is experiencing these difficulties, it is understood as a specific variant in which family stress levels reach a higher threshold than conventional ADHD. And in general, the 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 it from peer groups with prosocial tendencies and segregates it into marginal groups where disocial behaviors acquire normative value and power reinforcing).
The family history of such a case of comorbidity is characterized by poor parentality, low supervision of the infant’s habits outside the home and even abuses of all kinds and hardness . 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 of these parents, or both, to suffer serious mental pathologies (including antisocial disorder or chemical and non-chemical addictions). This situation also increases the risk of the child incurring the use of drugs, aggravating all their problems, as was seen in a previous section.
Suicide is not a disorder in itself, but a dramatic and painful consequence, which often implies a prolonged history of psychological pain. In fact, up to 50% of adolescents who try or achieve it suffer from some mental health problem , with an average evolution of two years taking the moment of the suicide act as a reference. It is known that patients with a diagnosis of ADHD are more likely to engage in suicidal behaviors, to present an autolytic ideation and even to cause themselves to be lesions of different considerations.
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 take their own lives at least once and that 5% arrive to die precisely for that cause. The risk increases when living with a major depression, a behavioral problem or a dependence on substances; 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 taken into account.
The cognitive alterations that these patients present, especially in areas such as attention and behavioral inhibition, are associated with an increased risk of suicidal behavior. So much so, that many studies on the epidemiology of suicide underline ADHD as a risk factor for this important health and social problem.