|Year : 2020 | Volume
| Issue : 1 | Page : 19-24
Child characteristics associated with comorbidities among children diagnosed with attention-deficit hyperactivity disorder
Abdallah S Ibrahem1, Ghada M Salah-Eldeen1, Haitham M.Abo Hashem1, Omnia A Aiad2
1 Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Psychiatry, Helwan Hospital for Mental Health, Cairo, Egypt
|Date of Submission||14-Oct-2019|
|Date of Decision||30-Oct-2019|
|Date of Acceptance||03-Nov-2019|
|Date of Web Publication||22-Jan-2020|
Omnia A Aiad
Department of Psychiatry, Helwan Hospital for Mental Health, Helwan
Source of Support: None, Conflict of Interest: None
Background More than half of children who are diagnosed with attention-deficit hyperactivity disorder (ADHD) were reported to have one or more comorbid psychiatric disorder. Our aim is to assess different comorbidities in children diagnosed with ADHD and to explore the association between the presence of such comorbidities and the characteristics of both the child and the family.
Patients and methods The study included 48 children with ADHD who fulfilled the inclusion criteria. The diagnosis of ADHD was made by semistructured clinical interview for both parents and child according to psychiatric sheet of Psychiatry Department of Zagazig University hospitals. Confirmation of diagnosis, severity, and subtype was done by revision and evaluation of child’s presentation according to DSM-5 criteria and the Conner’s Comprehensive Behavior Rating Scales (parent’s version). Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) was used to assess psychiatric comorbidities among children with ADHD.
Results Approximately 77.1% of children with ADHD had at least one psychiatric comorbidity. Overall, 41.7% of the population of this study had externalizing disorders (disruptive behavior disorders), whereas 52.1% had internalizing disorder, including mood disorders (25%) and anxiety disorders (29.1%). In addition, neurodevelopmental disorders were comorbid in 27.1% of the population sample. Statistically significant differences between different groups of comorbidities regarding academic performance and ADHD subtype and severity were found.
Conclusion Most children with ADHD have one or more comorbid psychiatric disorders. Children with ADHD and comorbidities are more prone to low academic performance and increased severity of ADHD.
Keywords: attention-deficit hyperactivity, comorbidity, conner’s
|How to cite this article:|
Ibrahem AS, Salah-Eldeen GM, Hashem HM, Aiad OA. Child characteristics associated with comorbidities among children diagnosed with attention-deficit hyperactivity disorder. Egypt J Psychiatr 2020;41:19-24
|How to cite this URL:|
Ibrahem AS, Salah-Eldeen GM, Hashem HM, Aiad OA. Child characteristics associated with comorbidities among children diagnosed with attention-deficit hyperactivity disorder. Egypt J Psychiatr [serial online] 2020 [cited 2020 Sep 27];41:19-24. Available from: http://new.ejpsy.eg.net/text.asp?2020/41/1/19/276397
| Introduction|| |
Attention-deficit hyperactivity disorder (ADHD) is a disorder with an early onset and a neurodevelopmental nature. Its prevalence ranges between 5.9 and 7.1% worldwide (Willcutt, 2012). ADHD is three times more frequent in boys than in girls (Biederman et al., 2005). The etiology of ADHD is still unclear. Family studies reported that heredity role is about 80–90%, indicating an important genetic role (Kessler et al., 2005). Moreover, environmental factors such as exposure to adverse circumstances during intrauterine or children life have been included in the etiology of ADHD (Plomp et al., 2009). Studies made about gene–environment interactions state that they may play an important role in ADHD (Thapar et al., 2012). Core characteristics of ADHD are pervasive and developmentally inappropriate inattention, hyperactivity, impulsivity, and distractibility (Faraone and Biederman, 1998). Children having ADHD usually have social, academic, and occupational difficulties, and ∼30–50% of them have persisting symptoms during adulthood (Kessler et al., 2005). Studies show that comorbid disorders among children with ADHD are very common. Approximately 50–70% of children with ADHD present with an externalizing disorder such as opposition defiant disorder (ODD) or conduct disorder (CD), whereas up to 64% present with an internalizing disorder such as depression and anxiety (Sciberras et al., 2014). Children with ADHD can also present with co-occurring internalizing and externalizing comorbidities in up to 22% of cases (Abikoff et al., 2002). Many cross-sectional studies have examined how comorbidities affect the functioning of children with ADHD (Humphreys et al., 2012) and have shown that children with ADHD and externalizing comorbidities are more prone to poorer peer functioning (Mikami and Lorenzi, 2011) and poorer psychosocial quality of life (Limbers et al., 2011). Studies examining the association between internalizing comorbidities and peer functioning of children with ADHD have produced mixed results. Some studies have found that internalizing comorbidities are associated with poorer peer functioning, whereas others have not (Booster et al., 2012). The aim of this study was to assess different comorbidities in children diagnosed with ADHD and to explore the association between the presence of such comorbidities and the characteristics of the child.
| Patients and methods|| |
This was a cross-sectional study. It was done at the outpatient clinic of child psychiatry at Helwan Hospital for mental health during the period from October 1, 2018, to March 30, 2019. A total of 48 children from both sexes, in the age group from 6–12 years old with DSM-5 diagnosis of ADHD, were selected by simple random sampling. They were selected after fulfilling the inclusion criteria from the children with ADHD who came with their caregivers to seek psychiatric advice and help from child psychiatry outpatient clinic. Excluded patients were those who refused to participate, those older than 12 years or younger than 6 years, those who had medical problem that could affect their mental health, and those who had below average IQ. Ethical committee approval and written informed consent were obtained. All participants enrolled in the study were subjected to the following psychometric assessments. Phase 1 included the following: (a) a semistructured interview for one of or both parents and the child according to psychiatric sheet of child psychiatry unite of helwan hospital for mental health for collecting detailed psychiatric history of the child and assessment of the child through a detailed interview including physical and mental state examination. (b) Stanford-Binet intelligence scale 5th edition (Roid and Pomplun, 2012) was designed to test intelligence and cognitive abilities, used for ages 2 to 89 years and provides a Full Scale IQ. (c) Conner’s Parent Rating Scale-revised L (Conners, 2001): the Arabic version translated by Dr. Abd El-Rakeeb A. Albehery (2011), was used. The national institute of mental health accepted its validity, reliability, and stability. It is a paper and pencil screening questionnaire designed to be completed by parents to assist in determining whether children between the ages of 3 and 17 years might have ADHD. It consists of 80 questions, which should be answered by parents, each followed by four choices: 0 (not at all), 1 (just a little), 2 (pretty much), or 3 (very much). In addition to diagnosis of ADHD, it evaluates the degree of attention deficit, hyperactivity, and impulsivity symptoms. (d) Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) (Sheehan et al., 1998): the MINI-KID is a structured clinical diagnostic interview designed to assess the presence of current DSM-IV and ICD-10 psychiatric disorders in children and adolescents age 6–17 years in a way that is comprehensive and concise. The interview is administered to the child/adolescent together with the parent(s), although it can be administered to adolescents without a parent present. The MINI-KID follows the structure and format of the adult version of the interview (MINI). Like the MINI, the MINI-KID is also organized in diagnostic sections/modules. Using branching tree logic, the instrument asks two to four screening questions for each disorder. Additional symptom questions within each disorder section are only asked if the screen questions are positively endorsed. All questions are in the binary ‘yes/no’ format. It takes approximately half an hour to administer. Ghanem et al. (2000), developed the Arabic version and Awaad et al. (2002), validated it. In phase 2, after the clinical assessment, participants were divided into five groups (children with ADHD only, ADHD+internalizing disorder, ADHD+externalizing disorder, ADHD+developmental disorder, and ADHD+2 or more co-occurring comorbidities) for comparison in relation to characteristics of the child.
After data collection, data were coded, entered, and analyzed using statistical package for social science was developed by IBM (The International Business Machines Corporation), New York, USA. Qualitative data were presented as frequencies and percentages. Quantitative data were presented as mean, SDs, and median. Qualitative independent variables were compared using χ2 test, whereas quantitative data of multiple independent groups were compared using analysis of variance test for normally distributed data. Correlation coefficient was used to assess the strength and direction of correlation between different quantitative variables. P value less than or equal to 0.05 was considered statistically significant.
| Results|| |
In the present study, 77.1% of children with ADHD had at least one psychiatric comorbidity. Overall, 41.7% of the population of this study had externalizing disorders (disruptive behavior disorders), whereas 52.1% had internalizing disorders, including mood disorders (25%) and anxiety disorders (29.1%). In addition, neurodevelopmental disorders were comorbid in 27.1% of the population sample. The most frequent reported psychiatric comorbidity in children with ADHD was ODD (31.2%), followed by nocturnal enuresis (NE) (29.1%), learning disability (LD) (18.8), major depressive disorder (MDD) (14.6%), generalized anxiety disorder (GAD) (14.6%), CD (12.5%), and post-traumatic stress disorder (PTSD) (12.5%) ([Table 1]). Regarding the association between presence of comorbidities and characteristics of the child, the results show a statistically significant increase in frequency of superior academic performance among children with ADHD alone and ADHD with externalizing disorder, a statistically significant increase in inattentive ADHD subtype among cases with ADHD+internalizing disorder, a statistically significant increase in hyperactive-impulsive ADHD subtype among cases with ADHD+externalizing disorder, and a statistically significant increase in combined subtype among cases with developmental and cases with co-occurring comorbidities. A statistically significant increase in ADHD severity among cases with co-occurring comorbidities was found as well ([Table 2]).
|Table 2 Relation between attention-deficit hyperactivity disorder groups according to comorbidity and child characteristics|
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| Discussion|| |
Most children with ADHD were reported to have one or more comorbid psychiatric disorders, which in turn could worsen the clinical picture and the quality of life of those children, complicate the diagnosis and management of their problems, and increase the likelihood of adverse long-term outcomes. As a result, accurate assessment of those children to identify the comorbid psychiatric disorders and the factors that may contribute to the development of these disorders over time are important for those children and their families (Flouri et al., 2017). Therefore, the current study was conducted to assess different comorbidities and explore the association between the presence of such comorbidities and the characteristics of both the child and the family in a sample of children diagnosed with ADHD at child psychiatry outpatient clinics at Helwan hospital for mental health, Cairo, Egypt.
The results of the present study show that 41.7% of the population had externalizing disorders (disruptive behavior disorders), whereas 52.1% had internalizing disorder including: mood disorders (25%) and anxiety disorders (29.1%). In addition, neurodevelopmental disorders were comorbid in 27.1% of the population sample. According to the present findings, the most frequent reported psychiatric comorbidity in ADHD children was ODD (31.2%), followed by NE (29.1%), LD (18.8), MDD (14.6%), GAD (14.6%), CD (12.5%), and PTSD (12.5%). This finding was consistent with different studies that had shown a high but various prevalence of ODD in children with ADHD. Comorbid ODD was reported by Elia et al. (2009), and Yüce et al. (2013), in 40 and 69.4% of children with ADHD, respectively. In addition, Amiri et al. (2013), reported enuresis in 17.5% of children with ADHD. Yüce et al. (2013), found enuresis in 21.3% of ADHD cases. The current findings are also in accordance with the results of Ambrosini et al. (2013), which showed a comorbid diagnosis of depressive disorder in 18.8% of children with ADHD, and the results of Tsang et al. (2015), which were 11.2% for GAD in children with ADHD.
Regarding broad categories of comorbidities, the population sample was divided into five main groups (ADHD only, ADHD+internalizing disorder, ADHD+externalizing disorder, ADHD+developmental disorder, and ADHD+2 or more co-occurring categories) for comparison in relation to different parameters, and statistical significant differences between different groups in academic performance and ADHD subtype and severity were found. Regarding children’s academic performance, the current results show a statistically significant increase in the frequency of superior academic performance among children with ADHD alone and ADHD with externalizing disorder and a statistically significant increase in frequency of failure among children with co-occurring comorbidities. This goes in line with Cuffe et al. (2015), who found that the odds for ADHD plus internalizing disorder were higher than the ADHD plus externalizing disorder group for poor academic performance. In contrary, Larson et al. (2011), reported that comorbidity of CD/ODD with ADHD negatively affects the academic performance outcome. In the context of the current study, this could be explained by the relatively high IQ among the group with ADHD and externalizing disorder which could compensate for their disruptive behavior and in turn improve their academic performance. In addition, the group with ADHD and externalizing disorder is only from high and moderate social classes which provides them with better opportunities for living and learning.
Regarding ADHD subtype in relation to categories of comorbidities, the current results show statistical significant increase in inattentive ADHD subtype among cases with ADHD+internalizing disorder, significant increase in hyperactive-impulsive ADHD subtype among cases with ADHD+externalizing disorder, and significant increase in combined subtype among cases with developmental and cases with co-occurring comorbidities. These results partially go in line with Armstrong et al. (2015), who found that children with ADHD and co-occurring co-morbidities were more likely to have the combined subtype (76%) than children in other groups. However, these findings are not in accordance with Amiri et al. (2013), and Yüce et al. (2013), who reported no relation between CD frequency with ADHD and ADHD subtypes.
Regarding ADHD severity, it was not an unexpected result of the current study to find a statistical significant increase in ADHD severity among cases with co-occurring comorbidities, which goes in line with the result of Armstrong et al. (2015), who found the most severe presentation among children with ADHD and co-occurring comorbidities.
This is a cross-sectional observational study, so causal factors or directionality of the associations cannot be determined and does not entail a follow-up strategy for patients, so future longitudinal studies need to be done. Moreover, the potential biases that may be introduced by the reliance on self-report data need to be considered. Information on birth, education, and family history was not verified through patient records.
| Conclusion|| |
By the end of our study, we came up with the following conclusions: more than half of children with ADHD have one or more comorbid psychiatric disorders. In addition, children with ADHD and comorbidities, especially co-occurring comorbidities, are more prone to low academic performance and increased severity of ADHD.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abikoff HB, Jensen PS, Arnold LE, Hoza B, Hechtman L, Pollack S et al.
(2002). Observed classroom behavior of children with ADHD: relationship to gender and comorbidity. J Abnorm Child Psychol 30:349–359.
Ambrosini PJ, Bennett DS, Elia J (2013). Attention deficit hyper activity disorder characteristics: II. Clinical correlates of irritable mood. J Affect Disord 145:70–76.
Amiri S, Shafiee-Kandjani AR, Fakhari A, Abdi S, Golmirzaei J, Rafi ZA, Safikhanlo S (2013). Psychiatric comorbidities in ADHD children: an Iranian study among primary school students. Arch Iran Med 16:113–119.
Armstrong D, Lycett K, Hiscock H, Care E, Sciberras E (2015). Longitudinal associations between internalizing and externalizing comorbidities and functional outcomes for children with ADHD. Child Psychiatry Human Dev 46:736–748.
Awaad M, Bishry Z, Hamed A, Ghanem M, Sheehan K, Sheehan D (2002). Comparison of the Mini International Neuropsychiatric Interview for Children (MINI-KID) with the Schedule for Affective Disorders and Schizophrenia for School Aged Children–Present and Lifetime Version (K-SADS-PL). In an Egyptian sample presenting with Childhood Disorders. Ain Shams University Library.
Biederman J, Kwon A, Aleardi M, Chouinard VA, Marino T, Cole H et al.
(2005). Absence of gender effects on attention deficit hyperactivity disorder: findings in nonreferred subjects. Am J Psychiatry 162:1083–1089.
Booster GD, DuPaul GJ, Eiraldi R, Power TJ (2012). Functional impairments in children with ADHD: unique effects of age and comorbid status. J Atten Disord 16:179–189.
Conners CK (2001). CRS-R: Conners’ rating scales-revised: technical manual. Multi-Health Systems XX:XX.
Cuffe SP, Visser SN, Holbrook JR, Danielson ML, Geryk LL, Wolraich ML, McKeown RE (2015). ADHD and psychiatric comorbidity: Functional outcomes in a school-based sample of children. J Atten Disord 10:177–187.
Elia J, Ambrosini P, Berrettini W (2009). ADHD characteristics: I. Concurrent co-morbidity patterns in children & adolescents. Child Adolesc Psychiatry Ment Health 2:15–21.
Faraone SV, Biederman J (1998). Neurobiology of attention-deficit hyperactivity disorder. Biol Psychiatry 44:951–958.
Flouri E, Midouhas E, Ruddy A, Moulton V (2017). The role of socio-economic disadvantage in the development of comorbid emotional and conduct problems in children with ADHD. Eur Child Adolesc Psychiatry 26:723–732.
Ghanem M, Ibrahim M, Elbehery A (2000). The translation group of the Arabic version of the Mini International Neuropsychiatric Interview for Children (MINI-Kid). In: Sheehan DV et al.
XXXX. XXXX: Department of Neuropsychiatry Ain Shams University.
Humphreys KL, Mehta N, Lee SS (2012). Association of parental ADHD and depression with externalizing and internalizing dimensions of child psychopathology. J Attent Disord 16:267–275.
Kessler RC, Adler L, Ames M, Barkley RA, Birnbaum H, Greenberg P et al.
(2005). The prevalence and effects of adult attention deficit/hyperactivity disorder on work performance in a nationally representative sample of workers. J Occ Env Med 47:565–572.
Larson K, Russ SA, Kahn RS, Halfon N (2011). Patterns of comorbidity, functioning, and service use for US children with ADHD. Psychiatry 127:462–470.
Limbers CA, Ripperger-Suhler J, Heffer RW, Varni JW (2011). Patient-reported Pediatric Quality of Life Inventory™ 4.0 Generic Core Scales in pediatric patients with attention-deficit/hyperactivity disorder and comorbid psychiatric disorders: feasibility, reliability, and validity. Value Health 14:521–530.
Mikami AY, Lorenzi J (2011). Gender and conduct problems predict peer functioning among children with attention-deficit/hyperactivity disorder. J Clin Child Adolesc Psychol 40:777–786.
Plomp E, Van Engeland H, Durston S (2009). Understanding genes, environment and their interaction in attention-deficit hyperactivity disorder: is there a role for neuroimaging? Neuroscience 164:230–240.
Roid GH, Pomplun M (2012). The Stanford-Binet intelligence scales. XXXX: The Guilford Press.
Sciberras E, Lycett K, Efron D, Mensah F, Gerner B, Hiscock H (2014). Anxiety in children with attention-deficit/hyperactivity disorder. Pediatrics 133:801–808.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E et al.
(1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59:22–33.
Thapar A, Cooper M, Jefferies R, Stergiakouli E (2012). What causes attention deficit hyperactivity disorder? Arch Dis Child 97:260–265.
Tsang TW, Kohn MR, Efron D, Clarke SD, Clark CR, Lamb C, Williams LM (2015). Anxiety in young people with ADHD: clinical and self-report outcomes. J Atten Disord 19:18–26.
Willcutt EG (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics 9:490–499.
Yüce M, Zoroglu SS, Ceylan MF, Kandemir H, Karabekiroglu K (2013). Psychiatric comorbidity distribution and diversities in children and adolescents with attention deficit/hyperactivity disorder: a study from Turkey. Neuropsychiatr Dis Treat 9:1791.
[Table 1], [Table 2]