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Article Excerpt
Abstract. Comorbidity with other psychological problems (PP) complicates the course of attention deficit-hyperactivity disorder (ADHD) and makes treatment more difficult. The purpose of the present study was to (a) study the correspondence between the perceptions of parents and teachers about PP, (b) determine which PP predict the severity of the manifestations of ADHD, and (c) analyze the role of age and learning disabilities (LD) in the development of PP and ADHD. The participants were 72 children with a clinical diagnosis of ADHD. The PP were measured using rating scales filled out by parents and teachers. The results showed high correspondence between the two informant groups in rating the problems of behavior and overactivity. However, agreement on emotional symptoms was much lower. Inattention, emotional lability, and conduct problems predicted the severity of the ADHD. Finally, the younger children with ADHD+LD experienced more associated problems than the older children.
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Attention deficit-hyperactivity disorder (ADHD) is one of the most frequently diagnosed childhood disorders, affecting approximately 5% of school-aged children (American Psychiatric Association, 2000). ADHD almost never occurs in a pure state, but is associated with other psychological problems (PP) at a rate much higher than would he found by mere chance. These behavioral and emotional problems present a serious obstacle to the academic, social, and emotional development of children with ADHD and negatively affect their adjustment to adult life. Thus, data have shown that emotional lability and social problems are better indicators of impairments in the daily life of the individual than the level of ADHD symptomatology per se due to the negative impact these problems have on academic, family, and work domains (Melia et al., 2006). Studies have provided valuable information about the moderator role comorbidity plays in interventions designed for students with ADHD. One of the objectives of the Multimodal Treatment Study of Children with ADHD (MTA; Jensen et al., 2001), in which 579 children participated, was to determine whether the clinical significance of potential ADHD + anxiety disorder (ADHD+ANX) or ADHD + oppositional disorder/conduct disorder (ADHD+ODD/CD) syndromes would yield better diagnostic decision-making, treatment planning, and treatment outcomes. Moderate evidence of interactions between parent-reported anxiety and ODD/CD status was noted in the response to treatment, indicating that children with ADHD and anxiety disorders (but without ODD/CD) were likely to respond equally well to the behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to medication treatments (with or without behavioral treatments), whereas children with multiple comorbid disorders (anxiety and ODD/CD) responded best to combined (medication and behavioral) treatments (Jensen et al.). There is also evidence indicating that children with pure ADHD generally obtain more benefits from cognitive-behavioral training in self-control than those with ADHD + ODD, who tend to function better with treatment combining psychological techniques with the administration of medication (Miranda & Presentacion, 2000).
In a review of 15 years of the literature on the most frequent comorbidity patterns, Jensen, Martin, and Cantwell (1997) concluded that the clinical course and evolution of ADHD generally worsened in the presence of comorbid problems, including conflictive parent-child interactions, poor school performance, risky driving behaviors, or risk of substance abuse and antisocial personality disorder. More recent studies have found that the severity of the symptoms of inattention and hyperactivity-impulsivity, as rated by parents and teachers, was related to externalizing and internalizing comorbid psychopathologies (Connor et al., 2003). In fact, Klassen, Miller, and Fine (2005) showed that comorbidity and the severity of ADHD symptoms have differential impacts on quality of life. Specifically, these researchers found that the children with ADHD in their study who had two or more comorbid disorders differed significantly from those with no comorbidity on the majority of the quality-of-life indicators such as physical health, mental health, self-esteem, general behavior, impact on the parents, and limitations of the family's activities.
Comorbidity also plays a role in the persistence of ADHD into adulthood, which occurs in between 35% and 60% of the cases (Faraone et al., 2000). The presence of associated problems, together with other factors like severity of the symptoms, traumatic childhood experiences, and conflictive family relationships, has been found to predict the persistence of the disorder (Barkley, Fisher, Smallish, & Fletcher, 2004; Kessler et al., 2005). A prospective clinical study documented the effectiveness of childhood and adolescent anxiety and mood and impulse-control disorders in predicting ADHD persistence (Biederman et al., 1996). Further, Peterson, Pine, Cohen, and Brook (2001) have shown an effect of adolescent obsessive-compulsive disorder (OCD) in predicting adult persistence of ADHD symptoms. Smalley et al. (2007) also provide data on this topic in a recent study. Specifically, in their adolescent sample, the lifetime diagnosis of ADHD was significantly associated with anxiety (odds ratio 2.4), as well as mood (odds ratio 2.9) and disruptive behavioral disorders (odds ratio 17.3).
With these considerations in mind, the objective of psychological evaluations in the school setting must not exclusively focus on identifying students who are experiencing ADHD. It is important also to identify possible socio/emotional and behavioral problems as a preliminary step in designing well-founded effective intervention programs. As Riccio and Rodriguez (2007) highlighted in general terms, "Integration of information relating to personality, behavior, and social-emotional competence as part of the psychological assessment with psychoeducational data can better inform service delivery and the outcomes of children and families served" (p. 243).
The focus of the present study was (a) to examine the PP that often accompany ADHD, as well as their relationship with the severity of the disorder; and (b) to analyze the role of learning disabilities and age in PP comorbidity. The following brief review of the literature on PP and ADHD consists of three parts: (a) the types and prevalence of PP that usually appear associated with ADHD; (b) the role of age in psychological problems and in the severity of ADHD; and (c) the relationships among ADHD, learning disabilities, and psychological problems.
ADHD and Comorbid Problems
More than half of the children diagnosed with ADHD have at least one other disorder, and according to community based-sampling, between 23% and 43% have two or more additional disorders (August, Realmuto, MacDonald, Nuget, & Crosby, 1996; Romano, Tremblay, Vitaro, Zoccolillo, & Pagani, 2005; Szatmari, Oxford, & Boyle, 1989). Much more worrisome is the situation observed in clinical samples, where 87% of the subjects with ADHD have a comorbid disorder, and 67% have two or more associated disorders (Kadesjo & Gillberg, 2001).
Between 30% and 67% of the children with a clinical diagnosis of ADHD meet the diagnostic criteria for oppositional/defiant disorder or dissocial disorder (Loeber, Burke, Lahey, Winters, & Zera, 2000; Rosello, Amado, & Bo, 2000). This subgroup of children with associated behavior problems are at risk of experiencing social rejection and maladjustment. In fact, these children produce more family stress and have more interpersonal conflicts with their parents, classmates, and teachers (Johnston & Mash, 2001; Miranda, Marco, & Grau, 2007).
In agreement with the numbers related to disruptive behavior problems, about 40% of children with ADHD with a clinical referral experience some type of internalization disorder (Rosello et al., 2000). The degree of overlap between the anxious psychopathologies (excessive anxiety, separation anxiety, social and simple phobias) and ADHD varies between 10% and 40% (Biederman, Newcom, & Sprich, 1991).
With regard to mood disorders (depression, dystimia), the findings are more inconsistent. Some studies have found that the comorbidity of these two types of psychopathologics lies between 20% and 30% (Spencer, Biederman, & Wrens, 1999), whereas others show lower prevalence, around 5% (MTA Coorperative Group, 1999a, 1999b). This divergence may be explained by, among other factors, the fact that the relationship between ADHD and depressive disorders is mediated by the presence of behavioral problems. In fact, when the behavioral problems are controlled, the association between ADHD and mood disorders is no greater than what is found in the typical population (Angold, Costello, & Erkanli, 1999).
Therefore, in the literature on ADHD, differences are observed with regard to the rates of comorbidity. Those differences may be due to factors like the age of the subjects, the nature of the disorder being studied, or even the informants or evaluation procedures used. Agreement on the perception of the comorbid problems in ADHD is commonly low to moderate between raters, school and home (Antrop, Roegers, Oosterland, & Van Oost, 2002). Furthermore, type of disorder seems to be viewed differently by parent versus teacher informants. Specifically, in some studies, parents seemed to be less reliable evaluators of the internalizing problems than teachers (Barldey, 1998), whereas other studies have shown parents to be more sensitive to detecting internalizing problems than teachers (Crystal, Ostrander, Chen,& August, 2001). Consequently, multiple ratings are recommended as they collectively provide more information about a child than a single rating.
Severity of ADHD, Developmental Course, and Comorbid Problems
Without a doubt, ADHD involves a delay in the maturation of different processes. However, this dimension has not been specified, nor has it been included in any of the explanatory models of the disorder. According to some experts (e.g., Barkley, 1998), the expression of ADHD problems changes with age. For example, while hyperactive symptoms tend to decrease with age, inattention symptoms represent a relatively pervasive developmental characteristic and are more frequent in older children.
The possible interrelationships between age, the severity of the symptoms of inattention and hyperactivity-impulsivity, and the PP of...
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