Multiple Comorbidities, Adverse Outcomes Common in Children With ADHD

Deborah Brauser

February 18, 2011

February 18, 2011 — Children with attention-deficit/hyperactivity disorder (ADHD) are often burdened with comorbid mental health and neurodevelopmental conditions and adverse functional outcomes, new research suggests.

In an analysis of more than 5000 children with ADHD, investigators found that these patients were significantly more likely to also have depression, anxiety, and/or a learning disability than children without ADHD.

They were also 4 times more likely to have activity restriction and 5 times more likely to have school problems.

On the basis of these findings, "therapeutic approaches should be responsive to each child's neurodevelopmental profile, tailored to their unique social and family circumstances, and integrated with educational, mental health, and social support services," write Kandyce Larson, PhD, from the Center for Healthier Children, Families, and Communities in the David Geffen School of Medicine at the University of California–Los Angeles, and colleagues.

According to the investigators, this is the first US population–based study to look at "the pattern of these comorbidities" in ADHD and their relationship with functioning and service use.

The study was published online February 7 in Pediatrics.

Poor Children at Greater Risk

The investigators evaluated data on 61,779 children between the ages of 6 and 17 years from the 2007 National Survey of Children's Health. Of these, 5028 had ADHD.

Parents were questioned about 10 potential comorbid disorders and conditions, including learning disabilities, conduct disorders, anxiety, depression, speech problems, autism spectrum disorders, hearing problems, epilepsy or seizures, vision problems, and Tourette's syndrome.

Parents also reported on school functioning, parent-child communication, social competence ratings, the Aggravation in Parenting scale, and preventive and mental health visits.

Although results showed that ADHD was significantly associated with all 10 comorbidities, the highest between-group differences were for a learning disability (46% vs 5%), a conduct disorder (27% vs 2%), anxiety (18% vs 2%), depression (14% vs 1%), and speech problems (12% vs 3%; all P < .05).

In addition, 67% of the ADHD group had at least 1 comorbid disorder (33% had just 1 other disorder, 16% had 2, and 18% had 3 or more).

"The risk for having 3 or more comorbidities was 3.8 times higher for poor vs affluent children (30% vs 8%)," report the researchers.

Individualized Treatment

The odds of having activity restriction were also higher for those with ADHD (odds ratio [OR], 4.14; 95% confidence interval, [CI], 3.34 – 5.15), as were the odds of having school problems (OR, 5.18; 95% CI, 4.47 – 6.01), grade repetition (OR, 3.71; 95% CI, 3.02 – 4.55), and poor parent-child communication (OR, 2.55; 95% CI, 1.84 – 3.52).

They also had significantly lower social competence scores and higher parent aggravation scores.

Finally, "functioning declined in a stepwise fashion with increasing numbers of comorbidities, and use of health and educational services and need for care coordination increased," report the investigators.

"These results have important implications for the organization and delivery of health care services for children with ADHD [and] support an emerging view that 'pure' ADHD, in the absence of comorbidities, occurs in a minority of cases," they add.

The researchers suggest that comprehensive screening for other problems should be routinely conducted for patients with ADHD, and tailored, individualized treatment profiles should be created.

However, they write that a recent study found that only 20% of physicians agree they are adequately trained to treat children with ADHD and comorbidity.

"These findings reinforce a need for greater integration of primary care with mental health, education, and social services."

The study was funded in part by the Maternal and Child Health Bureau of the Health Resources and Services Administration Interdisciplinary Maternal and Child Health Training Program and by the National Institutes of Health Loan Repayment Program. The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online February 7, 2011.

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