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Depression is one of the most common comorbidities seen in children and adolescents with ADHD1

Depression is one of the most common comorbidities seen in children and adolescents with ADHD1

“ADHD frequently presents with comorbid anxiety disorders, mood disorders, and affective instability.”2

-Gregory Mattingly, MD

Although attention-deficit/hyperactivity disorder (ADHD) and mood disturbances are distinct, they often share overlapping clinical features, including changes in brain structure and function, neurotransmitter dysregulation, and genetic contributions.3

Up to 50% of pediatric patients with ADHD have a diagnosis of comorbid depression.1,4,5 Depression in children and teens with ADHD is typically seen after the onset of ADHD.4

Older age, severity of ADHD-related impairments, genetic factors, and negative environmental conditions have been shown to increase the risk for depression.6

Depression and ADHD in children may present with similar features—such as poor concentration and irritability—which can make effective diagnosis and treatment difficult. However, poor concentration in mood disorders becomes prominent only during a depressive episode.7

Additional symptoms that distinguish primary depression from ADHD include7:


Dysfunctions in sleep


Anhedonia


Feelings of low self-worth

Children who have both ADHD and depression may have a greater burden of illness and poorer outcomes versus either condition alone.4

Bipolar disorder can also complicate the clinical picture of ADHD

Bipolar disorder occurs at a lower comorbid rate than depression in patients with ADHD, but is still present in up to 22% of children and adolescents with the disorder.1

  • Symptoms common to both conditions in children include labile mood, difficulty modulating emotions, and frequent “meltdowns.”7 However, children with ADHD may show significant changes in mood during the same day, whereas mood changes must last ≥4 days to be a clinical indicator of bipolar disorder7
  •  
  • A diagnosis of bipolar disorder is suggested by the presence of extreme mood shifts; prolonged periods of euphoria or depression; or thought disturbances that are episodic, ie, occurring several days at a time7

It is important to identify comorbid bipolar disorder or depression in pediatric ADHD patients, as these conditions increase risk for suicidal ideation.1

Anxiety disorders are commonly found in children with ADHD—with risk for anxiety increasing as a child grows older1,8,12

Studies have shown that up to 50% of children with ADHD suffer from anxiety.1 Anxiety disorder shares some common symptoms with ADHD, including restlessness and difficulty with focusing.7

  • Excessive worry or panic in the face of everyday stressors and somatic issues (stomachaches, muscle tension) points more strongly to an anxiety diagnosis7

When evaluating pediatric patients with ADHD for anxiety, it is important to note the following:

  • Anxiety has been shown to increase the severity of ADHD symptoms8
  • Some investigators advise caution when prescribing stimulant medications in pediatric patients with anxiety1

Anxiety disorders are commonly found in children with ADHD—with risk for anxiety increasing as a child grows older1, 8, 12

Studies have shown that up to 50% of children with ADHD suffer from anxiety.1 Anxiety disorder shares some common symptoms with ADHD, including restlessness and difficulty with focusing.7

  • Symptoms common to both conditions in children include labile mood, difficulty modulating emotions, and frequent “meltdowns.”7 However, children with ADHD may show significant changes in mood during the same day, whereas mood changes must last ≥ 4 days to be a clinical indicator of bipolar disorder7

When evaluating pediatric patients with ADHD for anxiety, it is important to note the following:

  • Anxiety has been shown to increase the severity of ADHD symptoms8
  • Some investigators advise caution when prescribing stimulant medications in pediatric patients with anxiety1

There is an observed link between childhood ADHD and the development of certain personality disorders

Longitudinal data has shown that children with attention-deficit/hyperactivity disorder (ADHD) are significantly more likely to develop personality disorders later in adolescence than those without the condition.9

  • One study found that approximately 60% of adults with personality disorders reported severe ADHD symptoms in childhood10

Cluster B personality disorders occur most commonly in adults with ADHD and include narcissistic personality disorder and borderline personality disorder.7,9 These personality disorders share certain clinical features with ADHD, including:

Disorganization

Emotional and cognitive dysregulation



Social intrusiveness

However, individuals with ADHD do not typically display the fear of abandonment or self-harm tendencies often seen in Cluster B personality disorders.7

Different hypotheses have been offered to explain the overlap between ADHD and personality disorders.7,9

  • Personality disorders may be seen as a natural outcome of ADHD in a certain segment of the population

  • It has been suggested that ADHD causes stress and distortions in important social relationships, leading to the eventual development of personality disorders

  • A more controversial theory is that, given their high degree of symptom similarity, ADHD and certain personality disorders may represent different manifestations of the same disorder
 

ADHD has been shown to convey a higher risk for antisocial behavior seen in conduct disorder (truancy, criminality, defiance of authority)—particularly if ADHD symptoms are severe or persist into adulthood.11 A meta-analysis of longitudinal data demonstrated significant linkages between ADHD and impulsive or risky social behaviors, including:

  • Difficulty maintaining financial stability (inability to save money, paying rent or credit cards late, buying on impulse)11

  • Risky sexual behavior (more partners, less use of contraception), which is linked to increased risk for pregnancy and sexually transmitted infections11
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References: 1. Clemow DB, Bushe C, Mancini M, Ossipov MH, Upadhyaya H. A review of the efficacy of atomoxetine in the treatment of attention-deficit hyperactivity disorder in children and adult patients with common comorbidities. Neuropsychiatr Dis Treat. 2017;13:357-371. 2. Mattingly GW, Anderson RH. Optimizing outcomes in ADHD treatment: from clinical targets to novel delivery systems. CNS Spectrums. 2016;21:1-11. 3. Faraone SV, Asherson P, Banaschewski T, et al. Attention-deficit/hyperactivity disorder. Nat Rev Dis Primers. 2015;1:1-23. 4. Chang Z, D’Onofrio BM, Quinn PD, Lichtenstein P, Larsson H. Medication for attention-deficit/hyperactivity disorder and risk for depression: A nationwide longitudinal cohort study. Biol Psychiatry. 2016;80(12):916-922. 5. Di Trani M, Di Roma F, Andriola E, et al. Comorbid depressive disorders in ADHD: The role of ADHD severity, subtypes and familial psychiatric disorders. Psychiatry Investig. 2014;11(2):137-142. 6. Jerrell JM, McIntyre RS, Mark Park Y-M. Risk factors for incident major depressive disorder in children and adolescents with attention-deficit/hyperactivity disorder. Eur Child Adolesc Psychiatry. 2015;24:65-73. 7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing, Inc; 2013. 8. Tsang TW, Kohn MR, Efron D, et al. Anxiety in young people with ADHD: clinical and self-report outcomes. J Atten Disord. 2015;19(1):18-26. 9. Miller CJ, Flory JD, Miller SR, Harty SC, Newcorn JH, Halperin JM. Childhood ADHD and the emergence of personality disorders in adolescence: a prospective follow-up study. J Clin Psych. 2008;69(9): 1477-1489. 10. Fossati A, Novella L, Donati D, Donini M, Maffei C. History of childhood attention deficit/ hyperactivity disorder symptoms and borderline personality disorder: a controlled study. Compr Psychiatry. 2002;43:369-377. 11. Barkley RA, Fischer M. The Milwaukee longitudinal study of hyperactive (ADHD) children. In: Hechtman L, ed. Attention Deficit Hyperactivity Disorder: Adult Outcome and Its Predictors. New York, NY: Oxford University Press; 2016:63-104. 12. Turgay A. A multidimensional approach to medication selection in treatment of children and adolescents with ADHD. Psychiatry. 2007;4(8):46-57.