Comorbidity is the co-occurrence of two or more disorders, and it’s very common among individuals diagnosed with attention deficit hyperactivity disorder (ADHD). According to a 2019 study, 60 to 90 percent of children with ADHD have at least one comorbid disorder, which may have lifelong effects.
Because ADHD presents differently among individuals, it’s challenging to diagnose. Even while the general public gets a better understanding about ADHD on social media, there are still many individual differences to consider and comorbid conditions to discern. The presence of comorbid conditions only adds complexity to the diagnosis and treatment of ADHD. That’s why understanding what they are and how they present is key for optimal patient care.
Many things can factor into the development of ADHD comorbidities, including:
- Genetics
- Epigenetics
- Chronic infections
- Inflammation
- Life stressors
- Trauma
- Childhood abuse
Given these realities, a holistic approach to patient care can help clinicians working with ADHD. Patients can benefit from early identification, clear diagnostic data, and education about navigating comorbid conditions. That way, they have multiple strategies and tools for wellbeing.
In this article, we’ll explore the comorbidity in ADHD, which conditions are most common, how they affect diagnosis, and tools that assist in clinical decision making.
Key Takeaways
- Over 60% of people with ADHD have at least one comorbid condition, requiring both to be treated together
- Comorbid conditions can complicate diagnosis and treatment of ADHD, so prompt identification is key
- Treatment typically involves a combination of medication, psychotherapy, and multimodal approaches for optimal care
Defining Comorbidity
Comorbidity refers to two or more disorders existing simultaneously. For example, a person may experience symptoms of ADHD along with symptoms of another comorbid psychiatric disorder.
When left unaddressed, comorbidities can lead to worse health outcomes, more complex clinical management, and higher healthcare costs.
The process of diagnosing and treating ADHD effectively means identifying any existing comorbid psychiatric disorders, such as anxiety, depression, or a learning disability. Treating one condition won’t necessarily resolve the symptoms of the other. For instance, treating ADHD won’t make the depressive symptoms of comorbid depression disappear. Both conditions need to be treated together to provide the patient with the best care.
The Impact of Comorbid Conditions on ADHD
ADHD looks different from patient to patient. Additionally, comorbid conditions can lead to more severe symptoms and greater challenges in day-to-day life. By identifying these co-occurring disorders earlier, clinicians can tailor treatment and give patients tools for better wellbeing throughout their lives.
A person with ADHD may also have comorbid conditions such as:
- Antisocial personality disorder
- Anxiety disorders
- Depression
- Bipolar disorder
- Mood disorders
- Learning disabilities
- Substance use disorders
While various reports cite different rates of comorbidity with ADHD, it’s generally agreed upon that clinicians working with ADHD populations—children, adolescents, and adults with ADHD—should have knowledge about comorbid conditions to get to the root of all of the patient’s symptoms.
ADHD Comorbidities: Autism Spectrum and Other Neurodevelopmental Conditions
ADHD often co-occurs with neurodevelopmental disorders such as autism spectrum disorder, learning disorders, and tic disorders. Read on for more information about the symptoms that may overlap or interact with ADHD symptoms.
Autism Spectrum Disorder
Autism spectrum disorder (ASD) is a neurodevelopmental condition. It presents in many ways and can affect: sensory processing, social communication, emotional regulation, and behavior. ASD usually appears in childhood and persists into adulthood.
Autism shares similarities with ADHD, including being a type of neurodiversity and sharing symptom expression. Some overlapping symptoms may include challenges with:
- Social skills
- Attention
- Concentration
Assessments like the Adult ADHD Self-Report Scale (ASRS) and Autism Spectrum Quotient (AQ) Questionnaire can help clinicians distinguish between the two, and empower patients with information on how each of these present individually and together.
- One study demonstrated that it was possible to discriminate between symptom profiles of ASD and ADHD in children.
- Another study demonstrated that children and adolescents with combined ADHD and ASD have more severe symptoms across all domains and an additive severity of sleep-related difficulties in this group.
Learning Disorders
Learning disorders are a group of conditions that affect a person’s ability to understand, process, or remember information. These disorders can impact a person’s performance in school, work, and daily life.
Some common types of learning disorders include:
- Dyslexia: Difficulty with reading, spelling, and writing
- Dyscalculia: Difficulty with math concepts and calculations
- Dysgraphia: Difficulty with handwriting and fine motor skills
- Auditory processing disorder: Difficulty processing and understanding auditory information
- Visual processing disorder: Difficulty processing and understanding visual information
It is estimated that 20-60% of individuals affected with ADHD also experience learning disorders. Addressing learning disabilities in children with ADHD is critical in order to support them in academic and daily life, and to help them reach their full potential.
A 2013 study showed that children with ADHD symptoms had significantly higher risk for reading, spelling, and math difficulties as measured by SDQ scores (Strengths and Difficulties Questionnaire).
Differences observed by gender:
- Reading and spelling difficulties were generally higher in boys (14.1%) vs girls (8.7%)
- For students with ADHD symptoms, girls were at higher risk for reading and spelling difficulties than boys.
- Math difficulties were higher in boys with high SDQ scores and girls in both high and low SDQ score categories
Tic Disorders
Tic disorders are characterized by sudden, uncontrollable movements or sounds, known as tics. These disorders can affect both children and adults, and children with ADHD are more likely than unaffected children to have tics.
- Up to 20% of children diagnosed with ADHD will develop a chronic tic disorder
- Half or more of children diagnosed with Tourette syndrome also have ADHD
Signs of ADHD typically emerge before the onset of tics, making early detection beneficial. The presence of tic disorders in individuals with ADHD can impact their behavior and learning, as tics may cause emotional tension, distract from daily tasks, and interfere with academic performance.
ADHD Comorbidities: Internalizing Disorders
ADHD also frequently co-occurs with internalizing disorders such as depressive disorder, bipolar disorder, and anxiety disorders. Read on to learn more about how these present and which tools help with identifying these conditions.
Depressive Disorders
Depressive disorder, also known as major depressive disorder, is a mental health condition characterized by persistent feelings of sadness, hopelessness, and a lack of interest in activities.
- Depression is estimated to be 2.7 times more prevalent among adults with ADHD than among the general adult population
- Up to 70% of people with ADHD will seek treatment for depression at least once
- Adolescents with ADHD are ten times more likely to suffer from depression
“Because children and adults with ADHD struggle with focusing, organizing tasks, and feeling restless, they might experience sadness, guilt, irritability, low self-confidence and helplessness. In some cases, these symptoms can signal depression.”
Both ADHD and depression can cause issues with concentration, motivation, and mood. For those with ADHD and depression, monitoring for suicidal thoughts or behaviors is vital, as this could indicate a severe form of depression needing immediate intervention.
Testing for depression as a comorbid condition of ADHD can give patients a clearer understanding of themselves. Plus, healthcare professionals can aid individuals with ADHD and depression in leading happier, more fulfilling lives.
Bipolar Disorder
Bipolar disorder is a mental health condition characterized by extreme mood swings, including periods of mania (high energy and activity) and depression (low energy and sadness).
ADHD and comorbid bipolar disorder share some symptoms, such as impulsivity, irritability, hyperactivity, emotional dysregulation, sleep problems, and problems with maintaining attention.
- Up to 20% of people with ADHD experience bipolar disorder comorbidity
With assessment of bipolar disorder and ADHD together, clinicians can assist individuals with ADHD and bipolar disorder in reaching optimal mental health and well-being.
Anxiety Disorders
Anxiety disorders are a group of mental health conditions characterized by excessive fear, worry, and nervousness. About half of adults with ADHD also have an anxiety disorder. While anxiety and ADHD can co-occur, having ADHD may also cause or exacerbate anxiety.
Symptoms of anxiety disorders can include:
- Persistent worry
- Feeling on edge
- Chronic stress
- Fatigue
- Trouble sleeping
Treatment for both ADHD and anxiety disorders typically includes medication, therapy, or a combination of both.
ADHD Comorbidities: Externalizing Disorders
Externalizing disorders, such as conduct disorder and oppositional defiant disorder, are characterized by disruptive, hyperactive, and aggressive behaviors. These disorders often co-occur with ADHD, further complicating diagnosis and treatment.
ADHD, Conduct Disorder, and Oppositional Defiant Disorder
Conduct disorder (CD) can be characterized by persistent aggression toward others and a pattern of rule-breaking behavior. Oppositional defiant disorder (ODD) is marked by ongoing defiance and anger-driven disobedience.
Diagnosing CD and ODD in children with ADHD involves a comprehensive evaluation, including:
- Clinical interviews
- Behavioral observations
- Questionnaires for parents, teachers, caregivers, and the patient
- Cognitive assessments
Accurate diagnosis along with ADHD is essential for supporting children with these disorders, to help them recognize their behavioral patterns, socialize more effectively, and better set and achieve their goals.
Diagnosing ADHD and Comorbid Conditions
Diagnosing ADHD and comorbid conditions can be challenging due to overlapping symptoms, but using tools that act as a diagnostic aid and strategies can help clinicians accurately identify and treat these conditions.
Diagnostic Tools and Strategies
Various diagnostic tools and strategies can help clinicians accurately diagnose ADHD and comorbid conditions. These tools include:
- Clinical interviews
- Detailed history-taking
- Behavioral observation
- Scientifically-validated scales
When it comes to getting subjective data to measure indicators of ADHD comorbidities, assessments often include:
- Adult ADHD Self-Report Scale (ASRS)
- Conner’s Adult ADHD Diagnostic Interview for DSM-IV (CAADID)
- Wender Utah Rating Scale (WURS)
- The Swanson, Nolan, and Pelham Rating Scale (SNAP-IV)
- Strengths and Weaknesses of Attention-Deficit/Hyperactivity Symptoms and Normal Behavior Scale (SWAN ADHD scoring scale)
- Vanderbilt ADHD Diagnostic Rating Scale (VADRS)
Using these diagnostic tools and strategies empowers healthcare professionals to better grasp the intricacies of ADHD and comorbid conditions, thereby facilitating more accurate diagnoses and the development of effective treatment plans.
How Creyos Can Help: Discover the ADHD Clinical Protocol and Report
With more patients self-diagnosing ADHD, based on symptoms they learn about online, there’s increased pressure on healthcare providers to offer clarity and accuracy around ADHD diagnosis and to disentangle comorbidities.
Psychiatrists have an opportunity to use objective measures to give patients clear answers about their cognition and an appropriate path for treatment or referrals. To meet the challenges of this rising demand, Creyos created a specific ADHD Clinical Protocol and Report, available right in the Creyos Health platform.
This report improves patient experiences and outcomes, while offering clinicians the confidence that comes with a protocol that is:
- Scientifically validated
- Built specifically to measure objective markers shown to be associated with ADHD
- A set of objective measurements that complement subjective questionnaires
- Effective for ongoing tracking of efficacy of medication and other treatment on cognition
- Flexibly administered in clinic or at home
Conclusion: A Complex and Prevalent Issue
ADHD comorbidity is a complex and prevalent issue that requires a comprehensive understanding of the various conditions that can co-occur with ADHD.
By recognizing the presence of comorbid conditions and employing a multimodal treatment approach that combines medication and psychotherapy, healthcare professionals can provide the best care and support for individuals with ADHD and comorbid conditions, helping them overcome their challenges and live fulfilling lives.