Psychiatric Comorbidities in Pediatric ADHD

Theresa R. Cerulli, MD: The other challenge in diagnosing ADHD [attention-deficit/hyperactivity disorder] is that the comorbid psychiatric conditions are so high. If you have ADHD, 75% of the time there’s a comorbid condition with it. In other words, straightforward ADHD exists alone in only 25% of your patients with ADHD. Seventy-five percent of the time there’s a comorbid psychiatric condition, and 60% of the time there are 2 or more comorbid psychiatric conditions with ADHD. It’s very challenging from a diagnostic standpoint and from a treatment standpoint, as you add comorbidities.

The data on outcomes is quite striking and concerning. What do I mean by that? Each time you add a comorbidity, you also add risk…. Here’s the mortality rate with ADHD as you add comorbidities. If you don’t have ADHD—you don’t have any comorbidities, no diagnoses—that’s baseline. Now let’s say you’re in the 25% of people who have ADHD alone. Your risk of mortality—what we call hazard ratio or odds ratio—goes up 1.56 over baseline. So your risk of dying is 1½ times greater if you have ADHD. Where’s that coming from? The data seem to point to accidents as a big problem: impulsive, inattentive decision-making in certain situations, like driving a car and playing sports sometimes. Those are elevating your risks. That’s just with ADHD.

The data I’m quoting are from JAMA Psychiatry in 2019. It was Dr [Shihua] Sun’s article. What if you add 1 comorbidity to the ADHD? It turns out that your odds ratio risk of mortality is 4.21 times greater than not having ADHD. How about 2-plus comorbidities? Your odds ratio of death goes up to 8.57—an 8½ times greater risk of dying from having ADHD with 2 or more comorbidities. With 3 comorbidities and ADHD, your mortality risk goes up 15.69—about 15½ times greater risk. Put that into clinical perspective. It’s very easy to hit ADHD with 2 comorbidities. All the time we hear this: ADHD and tic disorder and depression; ADHD and anxiety and depression. Let’s add a third 1, which is not uncommon by the time someone hits adulthood: ADHD, depression, anxiety, and substance abuse. These are real numbers. I’m talking mortality rates, not just patients struggling with some negative outcomes. As we know, those numbers are much greater. The comorbidities are extremely complicating diagnostically for our patients with ADHD. They’re also complicating our outcome and our treatment. Our treatments and our outcomes are quite frightening if we don’t get this right.

Transcript edited for clarity.