According to the latest scientific data, 63.8% of all those who suffer from ADHD, also suffer from another (comorbid) mental disorder. In the population, in general, around 20% suffer from a mental disorder.
In this article, I examine what they are and why they are linked to ADHD, as well as why 40% of all inmates convicted of serious crimes, all have ADHD, which was left untreated in childhood.
Dr. Russell A. Barkley, Ph.D. have made a video presentation on the comorbidity of ADHD & ODD back in 2014, and I find it very enlightening, so I have shared it with you here:
ADHD & ODD Comorbidity
(CLICK LINK TO WATCH)
In Thomas R. et al (2015), the latest study on world wide prevalence of ADHD was released. It showed that, on average, 7.2% of all people in the world, had ADHD. If your country has a prevalence lower than that, you are under diagnosing for ADHD, if higher you are over diagnosing for ADHD.
In Denmark, which is where I’m from, we use the WHO standard prevalence of 5%, which equals 280,000 people. In order to analyse the number of people afflicted by ADHD and some form comorbid mental disorder, I’ve done some digging, and here is the results:
So you’d think we’d medicate ADHD right?
No, the media and the health professionals here in Denmark are against medication for kids with ADHD. They still advocate for psychosocial treatment and fish oil supplements, as first line of “defence”. The foremost ADHD researcher have even, recently, been given a $250,000 grant for a study with the purpose of “Finding the strengths and potentials in kids with ADHD” or as he explains in the press release:
»At the same time, people with ADHD have an increased risk of being stigmatised, and ADHD is often referred to in negative terms. In these studies, the focus is on the child’s problems and focuses on what the child cannot do, whereas my study will look at the possible strengths and potentials, that the child may have, as a result of their ADHD symptoms. In other words, the possible positive sides of having hyperactive, impulsive and inattention problems, will be studied. «explains Per Hove Thomsen, Ph.D.
Well, well, I guess this explains why only 15% af all the people with ADHD, receive medication for it. Look how this have developed in the past 15 years:
The media says that “ADHD have exploded” over the past 15 years. Sure, if you believe that going from 0.7% to 14,6% in 15 years is a rapid growth, then there argument can be understood, but come on, let’s be real …
According to Dr. Russell A. Barkley, Ph.D., the main reason for comorbid disorders such as ODD or CD are based on a linkage between untreated ADHD in the child and untreated ADHD in the parent. This combination leads to a “Perfect Storm” in which the symptoms of the child’s untreated ADHD links up to the symptoms of the parent with untreated ADHD, resulting in a vicious cycle of the child reacting aggressively toward the parent, who themselves are impaired in their impulse and self-control, which in turn leads to an unpredictable and inconsistent childrearing environment, that further fuels the child’s symptoms, which festers as the disorder named Oppositional Defiant Disorder (ODD).
ODD or Conduct Disorder (CD) is described in ICD-10 (F91.3) as:
Conduct disorder, usually occurring in younger children, primarily characterized by markedly defiant, disobedient, disruptive behaviour that does not include delinquent acts or the more extreme forms of aggressive or dissocial behaviour. The disorder requires that the overall criteria for F91.- be met; even severely mischievous or naughty behaviour is not in itself sufficient for diagnosis. Caution should be employed before using this category, especially with older children, because clinically significant conduct disorder will usually be accompanied by dissocial or aggressive behaviour that goes beyond mere defiance, disobedience, or disruptiveness.
It is primarily the children that has the Predominately Combined Presentation (ADHD-C) that are in jeopardy of developing ODD, as this variant has been linked to being the root cause (in most cases) of being the trigger for a child developing ODD, as early as from age 4 or 5. Since most children are not being clinically diagnosed before age 7 or 8, this results in a serious behavioural disorder, that has had years to develop and take root in the psychosocial dynamics of both the child and the parent. Having these challenges, on a daily basis, takes great toll on the parent as well, and it is often the case that they develop Anxiety and/or Depression, due to their inability to solve the issues of parenting this child.
When the child reaches age 7, they begin in school, which sparks off yet another problem, namely the underdevelopment of the physical brain, that cause the child with untreated ADHD, to have a reduced ability for impulse and self-control, that equals that of a child aged 4 or 5.
This 30% reduction in the inhibitory systems, lead to outbursts of aggression and anger towards their surroundings, children and adults alike, and is devasting for the social interactions, friendships and academic achievements. Not because they are not able or willing to behave and learn, but simply because their emotions takes ahold of them and makes them act out.
If this pattern isn’t broken in earliest possible childhood, it can result in the ODD becoming an integral part of the behavioural identity of the child, and causes it to become isolated, anxious, depressed and violently reacting toward any (real or perceived) external stimuli, that does not fit into their current state of mood. If a child or adolescent with ODD is being denied having the target of their immediate desire, this can cause violations such as lying, stealing, assaulting others and may in adolescence lead to an increased sexual aggressiveness.
When the child turns 18 – 20 years, this childhood defiant behaviour has been nursed within them, for upward of 15 years, and is now in the core of their identity, which is why we see that so many of the people in prison for violent crimes, actually have ADHD and have developed a serious mental illness, Antisocial Personality Disorder.
Antisocial Personality Disorder
Antisocial Personality Disorder is characterised by disregard for social obligations, and callous unconcern for the feelings of others. There is gross disparity between behaviour and the prevailing social norms. Behaviour is not readily modifiable by adverse experience, including punishment. There is a low tolerance to frustration and a low threshold for discharge of aggression, including violence; there is a tendency to blame others, or to offer plausible rationalizations for the behaviour bringing the patient into conflict with society.
In earlier days, these were referred to as, Psychopaths. What is alarmning is, that 60% of convicted criminals (<= 18 yrs) and 30% of convicted criminals (> 18) have ADHD with some form of Conduct Disorder.
So lets take a look at how many people we’re taking about here. I have analysed data from Danmarks Statistik on the convictions of adolescents and adults, isolated to crimes that leads to imprisonment and the numbers shows that 3.6% of the under age 20 and 42.8% of those above age 20, have been convicted and imprisoned, based of the number of convictions per age group (under 20 n= 489) and (above 20 n= 7,313), divided by the prevalent number of people with ADHD and comorbid ODD(CD/ASPD (under 20 n= 13,500) and (above 20 n= 3,134).
This clearly shows, that untreated ADHD in childhood, which in 67% of all children with ADHD, can lead to ODD which then in turn, if untreated, can result in it becoming a part of the more than 40% of the population in the prison system in Denmark, being there due to untreated ADHD in childhood.
When I read the headlines of the newspapers where they state things like “Finally the medicating of children with ADHD have been broken after of 15 years of trying”, I have to wonder if those who advocate against medicinal treatment of children even know what the consequences of their actions, really are?
Do they (the advocates) understand that their misunderstood perception of ADHD medication for treatment of children (all the way down to age 4) have been proven, time and time again, to be safe and in 80% of all cases, effective in relieving the symptoms of ADHD in large part, as well as setting the child up for being able to receive, incorporate and use, social skills training and behavioural training, and thereby escaping the vicious cycle of psychosocial and genetically inherited, symptoms of the mental disorder called ADHD, for which they could have been treated?
I think not, and I hope that this article may enlighten them to the realistic possible future, that we are facing, here in Denmark.
Scientific Based Evidence that supports my conclusions and assumptions, in this article, can be found from this point forward
In medicine, comorbidity is the presence of one or more additional disorders (or diseases) co-occurring with a primary disease or disorder; or the effect of such additional disorders or diseases. The additional disorder may also be a behavioral or mental disorder.
ADHD and Comorbidity
According to the 4th Edition of “Attention-Deficit Hyperactive Disorder – Handbook for Diagnosis & Treatment” (Barkley et al. 2015), it is stated that;
There is no doubt that a diagnosis of attention-deficit/hyperactive disorder (ADHD) conveys a significant risk for other, coexisting psychiatric disorders. Indeed, as many as 67–80% of clinic-referred children and 80% or more of clinic-referred adults with ADHD have at least one other disorder, and up to half have two other disorders (Barkley, Murphy, & Fischer, 2008).
Harzard Ratios and Odds Ratio explained
Hazard Ratio [HR]
In survival analysis, the hazard ratio (HR) is the ratio of the hazard rates corresponding to the conditions described by two levels of an explanatory variable. For example, in a drug study, the treated population may die at twice the rate per unit time as the control population. The hazard ratio would be 2, indicating higher hazard of death from the treatment. Or in another study, men receiving the same treatment may suffer a certain complication ten times more frequently per unit time than women, giving a hazard ratio of 10.
Hazard ratios differ from relative risks in that the latter are cumulative over an entire study, using a defined endpoint, while the former represent instantaneous risk over the study time period, or some subset thereof. Hazard ratios suffer somewhat less from selection bias with respect to the endpoints chosen and can indicate risks that happen before the endpoint.
Odds Ratio [OR]
In statistics, the odds ratio (usually abbreviated “OR”) is one of three main ways to quantify how strongly the presence or absence of property A is associated with the presence or absence of property B in a given population. If each individual in a population either does or does not have a property “A”, (e.g. “high blood pressure”), and also either does or does not have a property “B” (e.g. “moderate alcohol consumption”) where both properties are appropriately defined, then a ratio can be formed which quantitatively describes the association between the presence/absence of “A” (high blood pressure) and the presence/absence of “B” (moderate alcohol consumption) for individuals in the population. This ratio is the odds ratio (OR) and can be computed following these steps:
- For a given individual that has “B” compute the odds that the same individual has “A”
- For a given individual that does not have “B” compute the odds that the same individual has “A”
- Divide the odds from step 1 by the odds from step 2 to obtain the odds ratio (OR).
The term “individual” in this usage does not have to refer to a human being, as a statistical population can measure any set of entities, whether living or inanimate.
If the OR is greater than 1, then having “A” is considered to be “associated” with having “B” in the sense that the having of “B” raises (relative to not-having “B”) the odds of having “A”. Note that this is not enough to establish that B is a contributing cause of “A”: it could be that the association is due to a third property, “C”, which is a contributing cause of both “A” and “B” (confounding).
The two other major ways of quantifying association are the risk ratio (“RR”) and the absolute risk reduction (“ARR”). In clinical studies and many other settings, the parameter of greatest interest is often actually the RR, which is determined in a way that is similar to the one just described for the OR, except using probabilities instead of odds. Frequently, however, the available data only allows the computation of the OR; notably, this is so in the case of case-control studies, as explained below. On the other hand, if one of the properties (say, A) is sufficiently rare (the “rare disease assumption“), then the OR of having A given that the individual has B is a good approximation to the corresponding RR (the specification “A given B” is needed because, while the OR treats the two properties symmetrically, the RR and other measures do not).
In a more technical language, the OR is a measure of effect size, describing the strength of association or non-independence between two binary data values. It is used as a descriptive statistic, and plays an important role in logistic regression.
Research & Scientific Results
Yoshimasu K. et al. (2012) wrote in their conclusion:
This population-based study confirms that children with ADHD are at significantly increased risk for a wide range of psychiatric disorders. Besides treating the ADHD, clinicians should identify and provide appropriate treatment for psychiatric comorbidities.
Attention-deficit/hyperactivity disorder was associated with a significantly increased risk of adjustment disorders (HR = 3.88), conduct/oppositional defiant disorder (HR = 9.54), mood disorders (HR = 3.67), anxiety disorders (HR = 2.94), tic disorders (HR = 6.53), eating disorders (HR = 5.68), personality disorders (HR = 5.80), and substance related disorders (HR = 4.03). When psychiatric comorbidities were classified on the internalization-externalization dimension, ADHD was strongly associated with coexisting internalizing/externalizing(OR = 10.6), or externalizing-only (OR = 10.0) disorders.
This study quantifies the extent of co-morbidity presented by offenders with ADHD, especially adults. The differences between risk estimates for youths and adults indicate an incremental effect in both frequency and severity for the development of further co-morbid pathology through adulthood. The findings have implications for clinical intervention and for criminal justice policy.
Eighteen studies with data for 1615 with ADHD and 3128 without ADHD were included. The risk (OR) of all psychiatric morbidity is increased among adult inmates with ADHD. Associations in youths with ADHD were restricted to mood disorder (OR 1.89, 95% confidence interval 1.09-3.28).
Among patients with ADHD, rates of criminality were lower during periods when they were receiving ADHD medication. These findings raise the possibility that the use of medication reduces the risk of criminality among patients with ADHD.
As compared with nonmedication periods, among patients receiving ADHD medication, there was a significant reduction of 32% in the criminality rate for men (adjusted hazard ratio, 0.68; 95% confidence interval [CI], 0.63 to 0.73) and 41% for women (hazard ratio, 0.59; 95% CI, 0.50 to 0.70). The rate reduction remained between 17% and 46% in sensitivity analyses among men, with factors that included different types of drugs (e.g., stimulant vs. nonstimulant) and outcomes (e.g., type of crime).
ADHD was associated with significantly increased mortality rates. People diagnosed with ADHD in adulthood had a higher MRR than did those diagnosed in childhood and adolescence. Comorbid oppositional defiant disorder, conduct disorder, and substance use disorder increased the MRR even further. However, when adjusted for these comorbidities, ADHD remained associated with excess mortality, with higher MRRs in girls and women with ADHD than in boys and men with ADHD. The excess mortality in ADHD was mainly driven by deaths from unnatural causes, especially accidents.
During follow-up (24·9 million person-years), 5580 cohort members died. The mortality rate per 10,000 person-years was 5·85 among individuals with ADHD compared with 2·21 in those without (corresponding to a fully adjusted MRR of 2·07, 95% CI 1·70-2·50; p<0·0001). Accidents were the most common cause of death. Compared with individuals without ADHD, the fully adjusted MRR for individuals diagnosed with ADHD at ages younger than 6 years was 1·86 (95% CI 0·93-3·27), and it was 1·58 (1·21-2·03) for those aged 6-17 years, and 4·25 (3·05-5·78) for those aged 18 years or older. After exclusion of individuals with oppositional defiant disorder, conduct disorder, and substance use disorder, ADHD remained associated with increased mortality (fully adjusted MRR 1·50, 1·11-1·98), and was higher in girls and women (2·85, 1·56-4·71) than in boys and men (1·27, 0·89-1·76).