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European Child & Adolescent Psychiatry
Published in: European Child & Adolescent Psychiatry 12/2017

01-12-2017 | Original Contribution

Comorbidity prevalence and treatment outcome in children and adolescents with ADHD

Authors: Laura Reale, Beatrice Bartoli, Massimo Cartabia, Michele Zanetti, Maria Antonella Costantino, Maria Paola Canevini, Cristiano Termine, Maurizio Bonati, on behalf of Lombardy ADHD Group

Published in: European Child & Adolescent Psychiatry | Issue 12/2017

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Abstract

Although ADHD comorbidity has been widely studied, some issues remain unsolved. This multicenter observational study aims to examine comorbid psychiatric disorders in a clinical sample of newly diagnosed, treatment naïve children and adolescents with and without ADHD and, to compare treatment efficacy based on the type of comorbidity. We performed an analysis of the medical records of patients identified from the Regional ADHD Registry database, enrolled in 18 ADHD centers in the 2011–2016 period. 1919 of 2861 subjects evaluated (67%) met the diagnostic criteria for ADHD: 650 (34%) had only ADHD, while 1269 (66%) had at least one comorbid psychiatric disorder (learning disorders, 56%; sleep disorders, 23%; oppositional defiant disorder, 20%; anxiety disorders, 12%). Patients with ADHD of combined type and with severe impairment (CGI-S ≥5) were more likely to present comorbidity. 382 of 724 (53%) followed up patients improved after 1 year of treatment. ADHD with comorbidity showed greater improvement when treated with combined interventions or methylphenidate alone. Specifically, combined treatment showed significant superiority for ADHD with learning disorders (ES 0.66) and ODD (ES 0.98), lower for ADHD with sleep or anxiety disorders. Training intervention alone showed only medium efficacy (ES 0.50) for ADHD and learning disorders. This study was the first describing comorbidity patterns of ADHD in Italy, confirming, in a multicenter clinical setting, that ADHD is more often a complex disorder. Findings highlight important diagnostic, therapeutic, and service organization aspects that should be broadly extended to ensure an appropriate and homogenous ADHD management.
Literature
1.
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th edn. American Psychiatric Publishing, ArlingtonCrossRef
2.
Centers for Disease Control and Prevention (2013) Mental health surveillance among children—United States, 2005–2011. MMWR 62:1–35
3.
Barkley RA, Russell A (2014) Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. Guilford Publications, New York
4.
Feinstein A (1970) The pre-therapeutic classification of co-morbidity in chronic disease. J Chron Dis 23:455–468CrossRefPubMed
5.
Caron C, Rutter M (1991) Comorbidity in child psychopathology: concepts, issues and research strategies. J Child Psychol Psychiatry 32:1063–1080CrossRefPubMed
6.
Angold A, Costello EJ, Erkanli A (1999) Comorbidity. Child Psychol Psychiatry 40(1):57–87CrossRef
7.
Blanco C, Wall MM, He JP (2015) The space of common psychiatric disorders in adolescents: comorbidity structure and individual latent liabilities. J Am Acad Child Adolesc Psychiatry 54(1):45–52CrossRefPubMed
8.
Gillberg C, Carlström G, Rasmussen P (1983) Hyperkinetic disorders in seven-year-old children with perceptual, motor and attentional deficits. J Child Psychol Psychiatry 24(2):233–246CrossRefPubMed
9.
Brown T (2000) Attention-Deficit Disorders and Comorbidities in children, adolescent and adults. American Psychiatric Press, Washington
10.
Biederman J, Monuteaux MC, Kendrick E, Klein KL, Faraone SV (2005) The CBCL as a screen for psychiatric comorbidity in paediatric patients with ADHD. Arch Dis Child 90:1010–1015CrossRefPubMedPubMedCentral
11.
Gillberg C, Gillberg IC, Rasmussen P et al (2004) Coexisting disorders in ADHD: implications for diagnosis and intervention. Eur Child Adolesc Psychiatry 13(Suppl 1):I80–I92PubMed
12.
Jensen PS, Martin D, Cantwell DP (1997) Comorbidity in ADHD: implication for research, practice and DSM V. J Am Acad Child Adolesc Psychiatry 36(8):1065–1079CrossRefPubMed
13.
Jensen PS, Hinshaw SP, Kraemer HC et al (2001) ADHD comorbidity findings from the MTA study: comparing comorbid subgroups. J Am Acad Child Adolesc Psychiatry 40:147–158CrossRefPubMed
14.
Kadesjö B, Gillberg C (2001) The comorbidity of ADHD in the general population of Swedish school-age children. J Child Psychol Psychiatry 42:487–492CrossRefPubMed
15.
Spencer TJ, Biederman J, Mick E (2007) Attention deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. Ambul Pediatr 7(suppl 1):73–81CrossRefPubMed
16.
Verkuijl N, Perkins M, Fazel M (2015) Childhood attention-deficit Hyperactivity disorder. Br Med J 350:h2168CrossRef
17.
Elia J, Ambrosini P, Berrettini W (2008) ADHD characteristics: I. Concurrent comorbidity patterns in children and adolescents. Child Adolesc Psychiatry Ment Health 2:15CrossRefPubMedPubMedCentral
18.
Larson K, Russ SA, Kahn RS, Halfon N (2011) Patterns of Comorbidity, Functioning, and Service Use for US children with ADHD, 2007. Pediatrics 127(3):462–470CrossRefPubMedPubMedCentral
19.
Wilens TE, Biederman J, Spencer TJ (2002) Attention deficit hyperactivity disorder across the lifespan. Annu Rev Med 53:113–131CrossRefPubMed
20.
Yoshimasu K, Barbaresi WJ, Colligan RC, Voigt RG, Killian JM, Weaver AL, Katusic SK (2012) Childhood ADHD is strongly associated with a broad range of psychiatric disorders during adolescence: a population-based birth cohort study. J Child Psychol Psychiatry 53(10):1036–1043CrossRefPubMedPubMedCentral
21.
Biederman J, Faraone SV (2005) Attention-deficit hyperactivity disorder. Lancet 366(9481):237–248CrossRefPubMed
22.
Jensen CM, Steinhausen HC (2015) Comorbid mental disorders in children and adolescents with attention-deficit/hyperactivity disorder in a large nationwide study. Atten Defic Hyperact Disord 7:27–38CrossRefPubMed
23.
Kadesjö B, Gillberg C (1999) Developmental coordination disorder in Swedish 7-year-old children. J Am Acad Child Adolesc Psychiatry 38:820–828CrossRefPubMed
24.
DuPaul GJ, Gormley MJ, Laracy SD (2013) Comorbidity of LD and ADHD: implications of DSM-5 for assessment and treatment. J Learn Disabil 46(1):43–51CrossRefPubMed
25.
Becker SP, Luebbe AM, Langberg JM (2012) Co-occurring mental health problems and peer functioning among youth with attention-deficit/hyperactivity disorder: a review and recommendations for future research. Clin Child Fam Psychol Rev 15:279–302CrossRefPubMed
26.
27.
Healy JM (2010) Different learners: identifying, preventing, and treating your child’s learning problems. Simon and Schuster, New York
28.
Thapar A, Cooper M, Eyre O, Langley K (2013) What have we learnt about the causes of ADHD? J Child Psychol Psyc 54:3–16CrossRef
29.
Gagliano A, Germanò E, Calamoneri F (2007) Specific learning diabilities and ADHD: characteristic of association. Giornale Neuropsichiatr Evolutiva 27:216–228
30.
Luoni C, Balottin U, Zaccagnino M, Brembilla L, Livetti G, Termine C (2013) Reading difficulties and attention deficit-hyperactivity behaviours: evidence of an early association in a non clinical sample. J Res Read 38:73–90CrossRef
31.
Ben-Ari Y (2008) Neuro-archaelogy: pre-symptomatic architecture and signature of neurological disorders. Trends Neurosci 31(12):626–636CrossRefPubMed
32.
Pettersson E, Anckarsäter H, Gillberg C, Lichtenstein P (2013) Different neurodevelopmental symptoms have a common genetic etiology. J Child Psychol Psychiatry 54(12):1356–1365CrossRefPubMed
33.
Pennington BF (2006) From single to multiple deficit models of developmental disorders. Cognition 101:385–413CrossRefPubMed
34.
Mick E, Biederman J, Jetton J, Faraone SV (2000) Sleep disturbance associated with attention deficit hyperactivity disorder: the impact of psychiatric comorbidity and pharmacotherapy. J Child Adolesc Psychopharmacol 10(3):223–231CrossRefPubMed
35.
36.
Accardo JA, Marcus CL, Leonard MB, Shults J, Meltzer LJ, Elia J (2012) Association between psychiatric comorbidities and sleep disturbances in children with attention deficit/hyperactivity disorder. J Dev Behav Pediatr 33(2):97–105PubMedPubMedCentral
37.
Banaschewski T, Neale BM, Rothenberger A, Roessner V (2007) Comorbidity of tic disorder and ADHD: conceptual and methodological consideration. Eur Child Adol Psychiatry 16(1):5–14CrossRef
38.
Connor DF (2015) Pharmacological management of pediatric patients with comorbid attention-deficit hyperactivity disorder oppositional defiant disorder. Pediatric Drugs 17:361–371CrossRefPubMed
39.
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA) (2011) Canadian ADHD practice guidelines, 3rd edn. CADDRA, Toronto
40.
Freitag CM, Hänig S, Schneider A, Seitz C, Palmason H, Retz W, Meyer J (2012) Biological and psychosocial environmental risk factors influence symptom severity and psychiatric comorbidity in children with ADHD. J Neural Transm 119(1):81–94CrossRefPubMed
41.
Canino G, Shrout PE, Rubio-Stipec M et al (2004) The DSM-IV rates of child and adolescent disorders in Puerto Rico: Prevalence, correlates, service use and the effects of impairment. Arch Gen Psychiatry 61(1):85–93CrossRefPubMed
42.
Newcorn JH, Halperin JM, Jensen PS et al (2001) Symptom profiles in children with ADHD: effects of comorbidity and gender. J Am Acad Child Adolesc Psychiatry 40:137–146CrossRefPubMed
43.
Didoni A, Sequi M, Panei P, Bonati M, Lombardy ADHD Registry Group (2011) One-year prospective follow-up of pharmacological treatment in children with attention-deficit/hyperactivity disorder. Eur J Clin Pharmacol 67:1061–1067CrossRefPubMed
44.
Panei P, Arcieri R, Vella S, Bonati M, Martini N, Zuddas A (2004) Italian attention-deficit/hyperactivity disorder registry. Pediatrics 114(2):514CrossRefPubMed
45.
46.
Bonati M, Reale L, Zanetti M, Lombardy ADHD Group (2015) A Regional ADHD Center-Based Network Project for the Diagnosis and Treatment of Children and Adolescents With ADHD. J Atten Disord. doi:10.​1177/​1087054715599573​ PubMed
47.
Bonati M, Reale L (2013) Reducing overdiagnosis and disease mongering in ADHD in Lombardy. Br Med J 347:f7474CrossRef
48.
Zanetti M, Cartabia M, Didoni A, Fortinguerra F, Reale L, Bonati M (2016) The impact of a model based clinical regional registry for attention deficit/hyperactivity disorder (ADHD). Health Informatics J. doi:10.​1177/​1460458216635835​ PubMed
49.
Wechsler D (1991) Wechsler intelligence scale for children, WISC-III, 3rd edn. Psychological Corporation, New York
50.
Wechsler D (2002) WPPSI-III administration and scoring manual. Psychological Corporation, San Antonio
51.
Wechsler D (2003) Wechsler Intelligence Scale for Children, 4th edn. Psychological Corporation, San Antonio
52.
Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, Williamson D, Ryan N (1997) Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36(7):980–988CrossRefPubMed
53.
Achenbach TM, Eofbrock C (1983) Manual for the child behaviour checklist. University of Vermont, Burlington
54.
Conners CK, Sitarenios G, Parker JD, Epstein JN (1998) The revised Conners’ Parent Rating Scale (CPRS-R): factor structure, reliability, and criterion validity. J Abnorm Child Psychol 26:257–268CrossRefPubMed
55.
Goyette CH, Conners CK, Ulrich RF (1978) Normative data on revised Conners’ parent and teacher rating scales. J Abnorm Child Psychol 6:221–236CrossRefPubMed
56.
Guy W (1996) ECDEU assessment manual for psychopharmacology: publication ADM 76-338. US Department of Health, Education and Welfare, Washington, pp 218–222
57.
58.
59.
Sharpe D (2015) Your Chi-Square test is statistically significant: Now What? Practical assessment. Res Eval 20:1–10
60.
Cohen J (1969) Statistical power analysis for the behavioral sciences. Academic Press, Cambridge
61.
Amiri S, Shafiee-Kandjani AR, Fakhari A et al (2013) Psychiatric Comorbidities in ADHD Children: An Iranian Study among Primary School Students. Arch Iran Med 16(9):513–517PubMed
62.
Bakare MO (2012) Attention deficit hyperactivity symptoms and disorder (ADHD) among African children: a review of epidemiology and co-morbidities. Afr J Psychiatry (Johannesbg) 15(5):358–361
63.
Bauermeister JJ, Shrout PE, Ramirez R (2007) ADHD correlates, co-morbidity, and impairment in community and treated samples of children and adolescent. J Abnorm Child Psychol 35(6):883–898CrossRefPubMedPubMedCentral
64.
Daviss WB (2008) A review of comorbid depression in pediatric ADHD: etiology, phenomenology, and treatment. J Child Adolesc Psychopharmacol 18:565–571CrossRefPubMedPubMedCentral
65.
Farbstein I, Mansbach-Kleinfeld I, Auerbach JG, Ponizovsky AM, Apter A (2014) The Israel Survey of Mental health among adolescent: prevalence of attention deficit hyperactivity disorder, comorbidity, methylphenidate use and help seeking patterns. Isr Med Assoc J 16(9):568–573PubMed
66.
Maric M, Prins PJ, Ollendick TH (2015) Moderators and mediators of youth treatment outcomes. Oxford University Press, OxfordCrossRef
67.
Collisson BA, Graham SA, Preston JL, Rose MS, McDonald S, Tough S (2016) Risk and protective factors for late talking: an epidemiologic investigation. J Pediatr 172:168–174CrossRefPubMed
68.
Jurado D, Alarcón RD, Martínez-Ortega JM, Mendieta-Marichal Y, Gutiérrez-Rojas L, Gurpegui M (2017) Factors associated with psychological distress or common mental disorders in migrant populations across the world. Rev Psiquiatr Salud Ment 10(1):45–58CrossRefPubMed
69.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE (2005) Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 62:593–602CrossRefPubMed
70.
Lehti V, Chudal R, Suominen A, Gissler M, Sourander A (2016) Association between immigrant background and ADHD: a nationwide population-based case-control study. J Child Psychol Psychiatry 57(8):967–975CrossRefPubMed
71.
Zenglein Y, Schwenck C, Westerwald E, Schmidt C, Beuth S, Meyer J, Palmason H, Seitz C, Hänig S, Freitag CM (2016) Empirically Determined, Psychopathological Subtypes in Children With ADHD. J Atten Disord 20:96–107CrossRefPubMed
72.
Frigerio A, Rucci P, Goodman R et al (2009) Prevalence and correlates of mental disorders among adolescents in Italy: The PrISMA study. Eur Child Adolesc Psychiatry 18(4):217–226CrossRefPubMed
73.
Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA (2015) Annual Research Review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescent. J Child Psychol Psychiatry 56(3):345–365CrossRefPubMed
74.
Park S, Kim BN, Cho SC, Kim JW, Shin MS, Yoo HJ (2015) Prevalence, correlates, and comorbidities of DSM-IV psychiatric disorders in children in Seoul, Korea. Asia Pac J Public Health 27:1942–1951CrossRef
75.
Barkley RA, Brown TE (2008) Unrecognized attention-deficit/hyperactivity disorder in adults presenting with other psychiatric disorders. CNS Spectr 13(11):977–984CrossRefPubMed
76.
77.
Jarret MA, Ollendick TH (2008) A conceptual review of the comorbidity of attention-deficit/hyperactivity disorder and anxiety: implication for further research and practice. Clin Psychol Rev 28(7):1266–1280CrossRef
78.
Fischer M, Barkley RA, Smallish L, Fletcher K (2002) Young adult follow-up of hyperactive children: self-reported psychiatric disorders, comorbidity, and the role of childhood conduct problems and teen CD. J Abnorm Child Psychol 30(5):463–475CrossRefPubMed
79.
Lundervold AJ, Hinshaw SP, Sørensen L, Posserud MB (2016) Co-occurring symptoms of attention deficit hyperactivity disorder (ADHD) in a population-based sample of adolescents screened for depression. BMC Psychiatry 16:46CrossRefPubMedPubMedCentral
80.
Lee MJ, Yang KC, Shyu YC, Yuan SS, Yang CJ, Lee SY, Lee TL, Wang LJ (2016) Attention-deficit hyperactivity disorder, its treatment with medication and the probability of developing a depressive disorder: a nationwide population-based study in Taiwan. J Affect Disord 189:110–117CrossRefPubMed
81.
Masi G, Millepiedi S, Mucci M, Bertini N, Pfanner C, Arcangeli F (2006) Comorbidity of obsessive-compulsive disorder and attention-deficit/hyperactivity disorder in referred children and adolescents. Compr Psychiatry 47(1):42–47CrossRefPubMed
82.
Faraone SV, Biederman J, Mennin D, Wozniak J, Spencer T (1997) Attention-deficit hyperactivity disorder with bipolar disorder: a familial subtype? J Am Acad Child Adolesc Psychiatry 36:1378–1387CrossRefPubMed
83.
Merikangas KR, Calkins ME, Burstein M et al (2015) Comorbidity of physical and mental disorders in the neurodevelopmental genomics cohort study. Pediatrics 135:e927–e938CrossRefPubMedPubMedCentral
84.
SINPIA (2015) L’assistenza ai minori con disturbi neuropsichici in lombardia. Prevenzione, diagnosi, cura e riabilitazione nella rete dei servizi di Neuropsichiatria dell’Infanzia e dell’Adolescenza. http://​goo.​gl/​egJ0EN. Accessed March 27, 2017
85.
Clavenna A, Cartabia M, Sequi M et al (2013) Burden of psychiatric disorders in the pediatric population. Eur Neuropsychopharmacol 23(2):98–106CrossRefPubMed
86.
van Ewijk H, Noordermeer SD, Heslenfeld DJ et al (2016) The influence of comorbid oppositional defiant disorder on white matter microstructure in attention-deficit/hyperactivity disorder. Eur Child Adolesc Psychiatry 25:701–710CrossRefPubMed
87.
March JS, Swanson JM, Arnold LE et al (2000) Anxiety as a predictor and outcome variable in the multimodal treatment study of children with ADHD (MTA). J Abnorm Child Psychol 28(6):527–541CrossRefPubMed
88.
MTA Cooperative Group (1999) A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 56(12):1073–1086CrossRef
89.
Busner J, Targum SD (2007) The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont) 4:28–37
90.
Evans SW, Owens JS, Bunford N (2014) Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. J Clin Child Adolesc Psychol 43:527–551CrossRefPubMed
91.
Pelham WE, Fabiano GA (2008) Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. J Clin Child Adolesc Psychol 37(1):184–214CrossRefPubMed
92.
93.
Button KS, Ioannidis JP, Mokrysz C et al (2013) Power failure: why small sample size undermines the reliability of neuroscience. Nat Rev Neurosci 14:365–376CrossRefPubMed
94.
Becker SP, Langberg JM, Evans SW (2015) Sleep problems predict comorbid externalizing behaviors and depression in young adolescents with attention-deficit/hyperactivity disorder. Eur Child Adolesc Psychiatry 24(8):897–907CrossRefPubMed
95.
Gipson TT, Lance EI, Albury RA, Gentner MB, Leppert ML (2015) Disparities in identification of comorbid diagnoses in children with ADHD. Clin Pediatr (Phila) 54:376–381CrossRef
96.
Melchior M, Pryor L, van der Waerden J (2015) Commonalities and specificities between attention deficit/hyperactivity disorder and autism-spectrum disorders: can epidemiology contribute? Eur Child Adolesc Psychiatry 24(8):855–858CrossRefPubMed
Metadata
Title
Comorbidity prevalence and treatment outcome in children and adolescents with ADHD
Authors
Laura Reale
Beatrice Bartoli
Massimo Cartabia
Michele Zanetti
Maria Antonella Costantino
Maria Paola Canevini
Cristiano Termine
Maurizio Bonati
on behalf of Lombardy ADHD Group
Publication date
01-12-2017
Publisher
Springer Berlin Heidelberg
Published in
European Child & Adolescent Psychiatry / Issue 12/2017
Print ISSN: 1018-8827
Electronic ISSN: 1435-165X
DOI
https://doi.org/10.1007/s00787-017-1005-z

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