Medical Comorbidity of Attention-Deficit/Hyperactivity Disorder in US Adolescents

The relationship between allergic rhinitis and attention deficit hyperactivity disorder: a systematic review and meta-analysis

Background

Numerous investigations have examined the potential link between allergic rhinitis (AR) and attention deficit hyperactivity disorder (ADHD). However, some studies show no association between the two diseases. The connection between these two conditions remains inconclusive. This study aimed to conduct a meta-analysis exploring the correlation between AR and ADHD.

Methods

We conducted systematic searches of the MEDLINE, EMBASE, Cochrane Library, ERIC, PubMed, Web of Science, and CINAHL databases, up to the year 2023. Subsequently, we conducted a meta-analysis using R 4.2.2, where we computed the pooled odds ratio with a 95% confidence interval to assess the relationship between AR and ADHD within studies exhibiting similar characteristics. Statistical heterogeneity was evaluated by computing the value using the Cochrane Intervention Manual's guidelines. Additionally, subgroup analyses were conducted by stratifying the study population according to gender, age, etc. Sensitivity analysis was performed by systematically removing individual studies.

Results

In this systematic review, we incorporated 12 eligible studies, collectively encompassing a sample size of 530,360 participants. Within the included studies, heterogeneity was observed, and the utilization of a random-effects model demonstrated a noteworthy correlation between children with ADHD and the presence of AR. Similarly, children with AR exhibited a significant correlation with the occurrence of ADHD. We also found some relationships in subgroup analyses.

Conclusion

A substantial correlation is evident between AR and ADHD in children and adolescents. AR may potentially contribute as a risk factor for the onset of ADHD, and conversely, ADHD may heighten the likelihood of developing AR.

Shared Genetic Liability across Systems of Psychiatric and Physical Illness

Epidemiological literature has shown that there are extensive comorbidity patterns between psychiatric and physical illness. However, our understanding of the multivariate systems of relationships underlying these patterns is poorly understood. Using Genomic SEM and Genomic E-SEM, an extension for genomic exploratory factor analysis that we introduce and validate, we evaluate the extent to which latent genomic factors from eight domains, encompassing 76 physical outcomes across 1.9 million cases, evince genetic overlap with previously identified psychiatric factors. We find that internalizing, neurodevelopmental, and substance use factors are broadly associated with increased genetic risk sharing across all physical illness domains. Conversely, we find that a compulsive factor is protective against circulatory and metabolic illness, whereas genetic risk sharing between physical illness factors and psychotic/thought disorders was limited. Our results reveal pervasive risk sharing between specific groups of psychiatric and physical conditions and call into question the bifurcation of psychiatric and physical conditions.

Somatic burden of attention-deficit/hyperactivity disorder across the lifecourse

OBJECTIVE

A thorough and comprehensive knowledge base on the extent of comorbidity of attention-deficit/hyperactivity disorder (ADHD) and somatic conditions is needed.

METHOD

We compared the prevalence of a wide range of somatic conditions in individuals with and without ADHD and described sex and lifecourse differences. Individuals with an ADHD diagnosis (N = 87,394) and age and sex-matched individuals without an ADHD diagnosis were identified from a large health claims dataset representative of the general German population, including both primary and specialized care (N = 4.874,754). Results were provided for the full sample as well as stratified for sex and age (<12 years, 13-17 years, 18-29 years, 30-59 years, ≥60 years).

RESULTS

The results showed that ADHD is associated with a wide variety of somatic conditions across the entire lifecourse. Specifically neurological disorders such as Parkison's disease (odds ratio [OR]: 5.21) and dementia (OR: 2.23), sleep-related disorders (OR: 2.38) and autoimmune disorders affecting the musculoskeletal, digestive, and endocrine system (fibromyalgia OR: 3.33; lupus OR: 2.17) are strongly and significantly associated with ADHD. Additionally, ADHD is associated with higher occurrence of common acute diseases typically treated by the general practitioner, hinting at an overall general lower health status. Sex differences in somatic comorbidity were not prominent. Age differences, in contrast, stood out: in particular endocrine, cardiovascular, and neurological disorders had an early onset in individuals with compared to individuals without ADHD.

CONCLUSION

This research underlines the high burden of disease due to somatic conditions among individuals with ADHD. The findings indicate the need for preventive measures to reduce comorbidity.

Comorbid ADHD and Pediatric Sickle Cell Disease: Prevalence and Risk Factors

Sickle cell disease (SCD) is a genetic blood condition that places youth at increased risk for deficits in complex attention suggestive of increased risk for Attention-Deficit/Hyperactivity Disorder (ADHD). We used systematic screening to assess the prevalence of ADHD in a clinic-based sample of youth with SCD and explored factors related to ADHD. Caregivers of 107 children with SCD (ages 7-11 years) completed routine psychosocial screening which included inattentive symptoms of ADHD. Follow-up diagnostic procedures were completed for patients with elevated inattentive symptoms to assess for ADHD diagnoses. Biomedical and social-environmental variables were examined from the screening and medical records. Twenty-six percent of patients showed elevated inattentive symptoms with 13% meeting diagnostic criteria for ADHD diagnoses. Most children (75%) who met criteria for ADHD had not been previously diagnosed. Disease severity did not predict inattentive symptoms or ADHD diagnoses, though a measure of chronic inflammation was associated with ADHD. Family functioning was related to elevated inattentive symptoms but not ADHD diagnoses. Children with SCD show relatively high rates of ADHD with many cases not detected through routine care. Screening for ADHD as part of hematology care may be a feasible strategy to improve identification and access to intervention.

Functional somatic symptoms in preschool attention-deficit/hyperactivity disorder: a secondary analysis of data from a randomized controlled trial of parent training

Children with attention-deficit/hyperactivity disorder (ADHD) can be more stress-vulnerable, and thereby, it has been suggested, prone to develop functional somatic symptoms (FSS) compared to their peers. In this paper, using data from 160 children aged 3-7 years with ADHD from the D'SNAPP study, a randomized controlled trial testing a parent training intervention, we addressed a number of questions about the role of FSS in ADHD. First, are FSS levels higher in an ADHD sample than in the children of the general population. Second, do FSS levels predict psychopathology and health-related quality of life (HRQoL) in ADHD samples. Third, does FSS levels moderate the effect of parent training on ADHD symptoms. We found that preschoolers with ADHD experienced more severe FSS than a general population-based sample (18.80% vs. 2.11%). Severe FSS were associated with increased psychopathology and impaired daily function and lower HRQoL. Level of baseline FSS did not moderate the effect of parent training on ADHD. FSS in preschool children with ADHD is associated with impaired daily functioning, but further research is warranted to determine the clinical impact of FSS in children with ADHD.

Paediatric asthma and non-allergic comorbidities: A review of current risk and proposed mechanisms

It is increasingly recognized that children with asthma are at a higher risk of other non-allergic concurrent diseases than the non-asthma population. A plethora of recent research has reported on these comorbidities and progress has been made in understanding the mechanisms for comorbidity. The goal of this review was to assess the most recent evidence (2016-2021) on the extent of common comorbidities (obesity, depression and anxiety, neurodevelopmental disorders, sleep disorders and autoimmune diseases) and the latest mechanistic research, highlighting knowledge gaps requiring further investigation. We found that the majority of recent studies from around the world demonstrate that children with asthma are at an increased risk of having at least one of the studied comorbidities. A range of potential mechanisms were identified including common early life risk factors, common genetic factors, causal relationships, asthma medication and embryologic origins. Studies varied in their selection of population, asthma definition and outcome definitions. Next, steps in future studies should include using objective measures of asthma, such as lung function and immunological data, as well as investigating asthma phenotypes and endotypes. Larger complex genetic analyses are needed, including genome-wide association studies, gene expression-functional as well as pathway analyses or Mendelian randomization techniques; and identification of gene-environment interactions, such as epi-genetic studies or twin analyses, including omics and early life exposure data. Importantly, research should have relevance to clinical and public health translation including clinical practice, asthma management guidelines and intervention studies aimed at reducing comorbidities.

Association between Polygenic Risk Scores for ADHD and Asthma: A Birth Cohort Investigation

OBJECTIVE

Shared genetic mechanisms have been hypothesized to explain the comorbidity between ADHD and asthma. To evaluate their genetic overlap, we relied on data from the 1982 Pelotas birth cohort to test the association between polygenic risk scores (PRSs) for ADHD (ADHD-PRSs) and asthma, and PRSs for asthma (asthma-PRSs) and ADHD.

METHOD

We analyzed data collected at birth, 2, 22, and 30 years from 3,574 individuals.

RESULTS

Subjects with ADHD had increased risk of having asthma (OR 1.92, 95% CI 1.01-3.66). The association was stronger for females. Our results showed no evidence of association between ADHD-PRSs and asthma or asthma-PRSs and ADHD. However, an exploratory analysis suggested that adult ADHD might be genetically associated with asthma.

CONCLUSION

Our results do not support a shared genetic background between both conditions. Findings should be viewed in light of important limitations, particularly the sample size and the self-reported asthma diagnosis. Studies in larger datasets are required to better explore the genetic overlap between adult ADHD and asthma.

Medical disorders in a Danish cohort of children with attention-deficit hyperactivity disorder

Studies have identified a higher prevalence of co-existing psychiatric and medical disorders in children with ADHD. There is a shortage of longitudinal studies providing an overview of potential medical disorders in children with ADHD. The objective of this study was to provide a broad overview of lifetime prevalence and relative risk of medical disorders in a nationwide Danish cohort of children with and without ADHD during the first 12 years of life. A population-based prospective follow-back cohort study used data from Danish national health registries to identify a cohort of all children born in Denmark between 1995 and 2002. The children were followed from birth until 12 years of age in two national registries. Children with ADHD had a significantly higher prevalence of recorded diagnoses across all included chapters of medical disorders in the ICD-10, except for neoplasms, where the association with ADHD was non-significant. The highest relative risk was observed for the chapter concerning diseases of the nervous system, with episodic and paroxysmal disorders being the most frequently registered underlying category. The findings indicate that children with ADHD have an increased risk of a broad range of medical disorders compared to the general population during the first 12 years of life, except for neoplasms.

Headache in ADHD as comorbidity and a side effect of medications: a systematic review and meta-analysis

There is mixed evidence on the association between headache and attention-deficit/hyperactivity disorder (ADHD), as well as headache and ADHD medications. This systematic review and meta-analysis investigated the co-occurrence of headache in children with ADHD, and the effects of ADHD medications on headache. Embase, Medline and PsycInfo were searched for population-based and clinical studies comparing the prevalence of headache in ADHD and controls through January 26, 2021. In addition, we updated the search of a previous systematic review and network meta-analysis of double-blind randomized controlled trials (RCTs) on ADHD medications on June 16, 2020. Trials of amphetamines, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate, and modafinil with a placebo arm and reporting data on headache as an adverse event, were included. Thirteen epidemiological studies and 58 clinical trials were eligible for inclusion. In epidemiological studies, a significant association between headache and ADHD was found [odds ratio (OR) = 2.01, 95% confidence interval (CI) = 1.63-2.46], which remained significant when limited to studies reporting ORs adjusted for possible confounders. The pooled prevalence of headaches in children with ADHD was 26.6%. In RCTs, three ADHD medications were associated with increased headache during treatment periods, compared to placebo: atomoxetine (OR = 1.29, 95% CI = 1.06-1.56), guanfacine (OR = 1.43, 95% CI = 1.12-1.82), and methylphenidate (OR = 1.33, 95% CI = 1.09-1.63). The summarized evidence suggests that headache is common in children with ADHD, both as part of the clinical presentation as such and as a side effect of some standard medications. Monitoring and clinical management strategies of headache in ADHD, in general, and during pharmacological treatment are recommended.

The Zonulin-transgenic mouse displays behavioral alterations ameliorated via depletion of the gut microbiota

The gut-brain axis hypothesis suggests that interactions in the intestinal milieu are critically involved in regulating brain function. Several studies point to a gut-microbiota-brain connection linking an impaired intestinal barrier and altered gut microbiota composition to neurological disorders involving neuroinflammation. Increased gut permeability allows luminal antigens to cross the gut epithelium, and via the blood stream and an impaired blood-brain barrier (BBB) enters the brain impacting its function. Pre-haptoglobin 2 (pHP2), the precursor protein to mature HP2, is the first characterized member of the zonulin family of structurally related proteins. pHP 2 has been identified in humans as the thus far only endogenous regulator of epithelial and endothelial tight junctions (TJs). We have leveraged the Zonulin-transgenic mouse (Ztm) that expresses a murine pHP2 (zonulin) to determine the role of increased gut permeability and its synergy with a dysbiotic intestinal microbiota on brain function and behavior. Here we show that Ztm mice display sex-dependent behavioral abnormalities accompanied by altered gene expression of BBB TJs and increased expression of brain inflammatory genes. Antibiotic depletion of the gut microbiota in Ztm mice downregulated brain inflammatory markers ameliorating some anxiety-like behavior. Overall, we show that zonulin-dependent alterations in gut permeability and dysbiosis of the gut microbiota are associated with an altered BBB integrity, neuroinflammation, and behavioral changes that are partially ameliorated by microbiota depletion. Our results suggest the Ztm model as a tool for the study of the cross-talk between the microbiome/gut and the brain in the context of neurobehavioral/neuroinflammatory disorders.

Non-mental diseases associated with ADHD across the lifespan: Fidgety Philipp and Pippi Longstocking at risk of multimorbidity?

Several non-mental diseases seem to be associated with an increased risk of ADHD and ADHD seems to be associated with increased risk for non-mental diseases. The underlying trajectories leading to such brain-body co-occurrences are often unclear - are there direct causal relationships from one disorder to the other, or does the sharing of genetic and/or environmental risk factors lead to their occurring together more frequently or both? Our goal with this narrative review was to provide a conceptual synthesis of the associations between ADHD and non-mental disease across the lifespan. We discuss potential shared pathologic mechanisms, genetic background and treatments in co-occurring diseases. For those co-occurrences for which published studies with sufficient sample sizes exist, meta-analyses have been published by others and we discuss those in detail. We conclude that non-mental diseases are common in ADHD and vice versa and add to the disease burden of the patient across the lifespan. Insufficient attention to such co-occurring conditions may result in missed diagnoses and suboptimal treatment in the affected individuals.

Attention-deficit/hyperactivity disorder has a state-dependent association with asthma: The role of systemic inflammation in a population-based birth cohort followed from childhood to adulthood

There is a high comorbidity between attention-deficit/hyperactivity disorder (ADHD) and asthma, and inflammation has been proposed as a potential pathophysiological mechanism behind this association. Most studies conducted so far have used a cross-sectional design, and none has evaluated the prevalence of asthma symptoms in patients with ADHD followed from childhood to adulthood. We relied on data from the 1993 Pelotas birth cohort to evaluate the association between ADHD and asthma in patients with distinct patterns of incidence, persistence and remission, and to explore the potential role of inflammatory markers in the comorbidity. We analyzed data from 3281 individuals from the 1993 Pelotas birth cohort collected at birth (1993), 11 years (2004), 18 years (2011), and 22 years (2015). Subjects were first classified according to their ADHD and asthma status as early-onset (EO) persistent (positive screening for ADHD at 11 years and diagnosis of ADHD according to DSM-5, except criterion E, at either 18 or 22 years), EO-remittent (positive screening for ADHD at 11 years only), late-onset (diagnosis of ADHD according to DSM-5, except criterion E, at 18 or 22 years only), or healthy subjects (negative for both conditions in all evaluation). After controlling for confounders, significant associations were observed between EO-remittent ADHD and EO-remittent asthma (OR 1.68, 95% CI 1.11-2.55), EO-persistent ADHD and EO-persistent asthma (OR 4.33, 95% CI 1.65-11.34), and between late-onset ADHD and late-onset asthma (OR 1.86, 95% CI 1.28-2.70), suggesting a state-dependent association. Serum interleukin-6 (IL-6) and C-reactive protein (CRP) were measured at the 18- and 22-year evaluations and compared between subjects positive for ADHD, asthma, and subjects with both or none conditions, regardless of the previously defined trajectories. Subjects with comorbid ADHD and asthma presented higher levels of IL-6 at the 18- and 22-year evaluations when compared to subjects negative for both conditions. Our results demonstrate a state-dependent association between ADHD and asthma despite underlying trajectories. Higher levels of serum IL-6 in patients with both conditions suggest that a pro-inflammatory environment might have a role in the pathophysiological mechanisms underlying the comorbidity.

Association between attention deficit hyperactivity disorder and aggression subscales in adolescents

INTRODUCTION

The aim of this study is to identify the association between Attention Deficit Hyperactivity Disorder (ADHD) proneness and aggressive propensity in adolescents.

METHODS

A quantitative, large-scale, cross-sectional study was performed from April to May 2016 in Korea. The survey questionnaire included overall health behaviors, as well as scales for assessing ADHD proneness (revised short form of the Conners-Wells Adolescent Self-Report Scale; CASS[S]) and aggressive behavior (Buss-Perry Aggression Questionnaire; BPAQ) in adolescents. Area under the receiver operator characteristic (AUROC) curves was constructed to determine the cut-off value of total aggression score for discriminating ADHD proneness.

RESULTS

A total of 2,432 students participated in the survey, and 1,872 of them completed the questionnaire, indicating a response rate of 77.0%. Based on CASS(S), 33 (1.8%) subjects were classified as the ADHD group. AUROC curve analysis showed that a score of 68.5 points had higher sensitivity (83.3%) and specificity (69.4%) to discriminate ADHD proneness. ADHD proneness was significantly associated with higher aggression subdomain scores (physical, verbal, anger, and hostility). Especially, anger and hostility had a stronger relationship with ADHD proneness than did physical and verbal aggression. A multivariable analysis demonstrated that ADHD proneness was significantly related to body mass index in the top 10% of the study population, alcohol consumption, gastrointestinal trouble, daytime sleepiness, and total aggression score of 68.5 points or higher. Adolescents who had total aggression scores of 68.5 points or higher showed a 9.8-fold (95% confidence interval [CI] 3.3-28.8) higher risk of ADHD compared with those who had scores less than 68.5 points.

CONCLUSIONS

Our results demonstrated that ADHD proneness was significantly associated with aggression propensity. In particular, anger and hostility were more closely associated with ADHD proneness than were other aggression subdomains.

Impact of the Guided Self-Determination Intervention among Adolescents with Co-Existing ADHD and Medical Disorder: A Mixed Methods Study

Adolescents with ADHD are at increased risk of having a co-existing medical disorder. Research shows that having co-existing ADHD and a medical disorder interferes with the adolescents' daily life, creating a dual task that cannot be managed as two independent disorders. Interventions to support adolescents in managing the dual task of living with co-existing ADHD and medical disorder are needed. The Guided-Self-Determination intervention might be suitable for this population, as it is an empowerment-based intervention facilitating patient involvement and self-management of a disease. The purpose of this study was to evaluate how the Guided Self-Determination intervention impacted 10 adolescents with ADHD and a co-existing medical disorder. The study used a convergent mixed methods design. Quantitative data measuring support from nurses, support from parents, and self-management were collected though self-reported questionnaires at baseline, 3 months, and 6 months and were analyzed with descriptive statistics. Qualitative data capturing the adolescents' experiences of the intervention and the intervention's impact on support from nurses, parents, and self-management were collected through semi-structured interviews and analyzed thematically. Results of the quantitative and qualitative analyses were integrated in a mixed methods analysis. The integrated results suggest that this intervention may improve adolescents' management of the difficulties of living with co-existing ADHD and a medical disorder, and that self-insight and nurse support are prerequisites for developing self-management strategies. However, the results showed that the intervention did not impact parental support. Further research is needed to evaluate the impact of the intervention on a larger scale.

The association between ADHD and physical health: a co-twin control study

Attention-deficit/hyperactivity disorder (ADHD) has been associated with increased risk for physical comorbidity. This study used a twin cohort to investigate the association between physical diseases and phenotypic variations of ADHD. A twin cohort enriched for ADHD and other neurodevelopmental conditions were analysed. The Attention Problems subscale of the Child Behavior Checklist/Adult Behavior Checklist (CBCL/ABCL-AP) was used to measure the participants’ severity of ADHD symptoms. Physical health issues were obtained with a validated questionnaire and were tested in relation to ADHD symptom severity in a co-twin control model. Neurological problems were significantly associated with a diagnosis of ADHD. A conditional model for the analysis of within-twin pair effects revealed an inverse association between digestive problems and the severity of ADHD symptoms, after adjusting for co-existing autism spectrum disorder and ADHD medications. Our findings suggest that individuals with ADHD are susceptible to neurological problems, why a thorough neurological check-up is indicated in clinical practice for this population. In addition, health conditions of digestive system could be considered as a non-shared environmental factor for behavioral phenotypes in ADHD. It supports the possible role of gut-brain axis in the underpinnings of ADHD symptoms, at least for a subgroup of individuals with certain genetic predisposition.

Attention deficit hyperactivity disorder and gastrointestinal morbidity in a large cohort of young adults

BACKGROUND

Although the association of attention deficit hyperactivity disorder (ADHD) with psychiatric disorders is well known, its association with somatic diseases is unclear. Only few studies have investigated the gastrointestinal (GI) morbidity in adult patients with ADHD.

AIM

To measure gastrointestinal comorbidity and its burden on healthcare in young adults with ADHD.

METHODS

The cohort included subjects aged 17-35 years recruited to the Israel Defense Forces in 2007-2013, 33380 with ADHD and 355652 without (controls). The groups were compared for functional and inflammatory conditions of the gastrointestinal tract and clinic and specialist visits for gastrointestinal symptoms/disease during service (to 2016). Findings were analyzed by generalized linear models adjusted for background variables.

RESULTS

Compared to controls, the ADHD group had more diagnoses of functional gastrointestinal disorders (referred to as FGID), namely, dyspepsia [odds ratio (OR): 1.48, 95% confidence interval (CI): 1.40-1.57, P < 0.001], chronic constipation (OR: 1.64, 95%CI: 1.48-1.81, P < 0.001), and irritable bowel syndrome (OR: 1.67, 95%CI: 1.56-1.80, P < 0.001) but not of organic disorders (inflammatory bowel disease, celiac disease). They had more frequent primary care visits for gastrointestinal symptoms [rate ratio (RR): 1.25, 95%CI: 1.24-1.26, P < 0.001] and referrals to gastrointestinal specialists (RR: 1.96, 95%CI: 1.88-2.03, P < 0.001) and more episodes of recurrent gastrointestinal symptoms (RR: 1.29, 95%CI: 1.21-1.38, P < 0.001). Methylphenidate use increased the risk of dyspepsia (OR: 1.49, 95%CI: 1.28-1.73, P < 0.001) and constipation (OR: 1.42, 95%CI: 1.09-1.84, P = 0.009).

CONCLUSION

ADHD in young adults is associated with an excess of FGID and increased use of related health services. Research is needed to determine if an integrative approach treating both conditions will benefit these patients and cut costs.

Association between childhood asthma and attention deficit hyperactivity or autism spectrum disorders: A systematic review with meta-analysis

BACKGROUND

Children with asthma are at risk of depression and anxiety and growing evidence suggest they may also be at risk of attention deficit hyperreactivity disorder (ADHD) and autism spectrum disorder (ASD). Here, we conducted a systematic review with meta-analysis of studies investigating association between asthma and ADHD or ASD in children.

METHODS

A comprehensive search using PubMed, EMBASE and Cochrane Library databases was completed in March 2019. Observational human studies published in English, clinic-based or population-based with a healthy comparator group, evaluating asthma-ADHD or asthma-ASD overlap in children 18 years or younger using categorical diagnoses (yes/no) were considered for inclusion. Random effects meta-analysis models were used to analyse data. The Newcastle Ottawa Scale was used to evaluate risk of bias.

RESULTS

A total of 25 asthma-ADHD studies were included of which 17 showed significant positive associations and one a negative association: 17/25 studies were population-based, 19/25 were cross-sectional or cohort studies and 7/25 had a low risk of bias. We performed a meta-analysis of 23 of the studies, which showed a significant association between asthma and ADHD: odds ratio (OR) 1.52 (1.42-1.63), P < .001, I2 = 60%. All studies were adjusted for age and sex and a large proportion; that is, 19/23 were further adjusted for relevant confounders. Seventeen asthma-ASD studies were included, whereof 7 showed a positive association and 3 a negative association; 8/17 were population-based with a cross-sectional study design and 4/17 had a low risk of bias. We performed a meta-analysis of 14 of the studies, which did not show a significant association between asthma and ASD: OR 1.12 (0.93-1.34), P = .24, I2 = 89%. All studies were adjusted for age and sex and 10/14 were further adjusted for relevant confounders.

CONCLUSIONS

This systematic review with meta-analyses shows a significant overlap between asthma and ADHD, but not between asthma and ASD in children. Clinicians taking care of children with asthma or ADHD should be aware of such association to aid an early diagnosis and treatment of such comorbidity.

Adolescents' Perceptions of Living With Co-Existing ADHD and Medical Disorder in Denmark

AIM

The study aim was to explore adolescents' with co-existing ADHD and medical disorder (MD) perceptions of everyday life and support from parents and healthcare professionals.

DESIGN AND METHODS

In this qualitative study, 10 adolescents aged 13-17 years diagnosed with ADHD and a MD were included from a general pediatric hospital clinic and a child and adolescent psychiatric hospital clinic. Data obtained through semi-structured interviews were analyzed using thematic analysis.

RESULTS

The adolescents' perceptions were categorized into four themes: 1) ADHD perceived as part of the adolescent's self-understanding - yet with daily frustrations, 2) MD perceived as an interruption in everyday life, 3) ADHD and MD - an overlooked dual task, and 4) the need for supportive relationships in navigating ADHD and MD.

CONCLUSION

Living with co-existing ADHD and MD is a complex dual task, as ADHD and MD interfere with each other in everyday life. However, the adolescents overlook the dual task as they believe their difficulties would be resolved if the MD was eliminated. Moreover, supportive relationships are essential in navigating the complexities in living with co-existing ADHD and MD. Nevertheless, the adolescents take a passive role in the encounters with the healthcare professionals, whereas they are more active in encounters with peers, parents and teachers.

PRACTICE IMPLICATIONS

Healthcare professionals treating and caring for adolescents with co-existing ADHD and MD need interventions facilitating patient involvement in a patient-centered approach to support both adolescents and healthcare professionals in recognizing the dual task of having co-existing ADHD and MD.

Pediatric Migraine and Academics

PURPOSE OF REVIEW

The purpose of this review is to examine the multitude of factors which may impact learning and academic performance in patients with pediatric migraine.

RECENT FINDINGS

A range of associations of varying degree were noted between pediatric migraine and conditions such as ADHD, learning disabilities, sleep disorders, and psychiatric comorbidities with regard to headache pain and school functioning. Recent literature highlights the importance of sleep in relation to headache, mood disorders, and learning in youth and the emerging role of perfectionism. Children with migraine remain at risk for school related and learning difficulties which may be primarily due to pain, due to other medical and psychiatric comorbidities commonly found in this population, or a combination. The relationships are complex and further studies are needed to clearly elucidate the shared biological and environmental pathophysiologic mechanisms.

ADHD Is Comorbid to Migraine in Childhood: A Population-Based Study

Objective: Recurrent headaches and ADHD are prevalent in the pediatric population. Herein, we assess if ADHD is comorbid to headaches overall, to headache subtypes (e.g., migraine), and to headache frequency. Method: Informed consent and analyzable data were obtained for 5,671 children aged 5 to 12 years (65.9% of the target sample). Parents and teachers were interviewed using validated questionnaires based on the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5). Relative risks were modeled using univariate and multivariate analyses. Results: As contrasted to nonheadache controls, the prevalence of ADHD was significantly higher in children with migraine (p < .001) but not in those with tension-type headaches. In children with migraine, risk of ADHD increased as a function of headache frequency (p < .05). Conclusion: Migraine and frequent migraine are comorbid to ADHD. Future studies should focus on the impact of the association on the burden to the children and their families.

The Complexities of Everyday Life and Healthcare Utilization in Danish Children With ADHD: A Mixed Methods Study

PURPOSE

To explore and describe everyday life and hospital-based healthcare experiences and utilization in families of children with ADHD in Denmark.

DESIGN AND METHODS

The present work is a multistage, mixed methods study. The design consists of three individual studies: a meta-synthesis, a focused ethnographic study, and a historical cohort study.

RESULTS

The integrated findings show that: 1) parental stressors affect everyday life and hospital-based service use; 2) parents have concerns for their child from early childhood and fight to have their concerns recognized; and 3) healthcare professionals are important for parents to navigate the persistent challenges of everyday life.

CONCLUSIONS

Having a child with ADHD pervades everyday life and children with ADHD use more medical and psychiatric services in hospitals during the first 12 years of life than children without ADHD. The findings demonstrate a vulnerable everyday life experience and highlight the importance of the families being recognized, accepted, and respected in hospital-based healthcare services from early childhood.

PRACTICE IMPLICATIONS

Healthcare professionals need to recognize the challenges the family of a child with ADHD faces and to acknowledge that ADHD pervades all aspects of everyday life and all other healthcare issues. It is important for healthcare professionals, regardless of specialty, to engage with individual families and to positively contribute to the medical and psychiatric healthcare experience.

Health Behaviors, Physical Health, and Health Care Utilization in Children With ADHD

Objective: To compare health behaviors, physical health outcomes, and health care utilization between children with and without ADHD. Method: In this cross-sectional study, we obtained data for children with and without ADHD from the Korean National Health and Nutrition Examination Survey. To investigate the association between ADHD and health outcomes, we estimated the adjusted prevalence ratios (APRs) in these groups. Results: Among 10,838 children aged 7 to 18 years with and without ADHD, those with ADHD had significantly higher APRs for overall health problems, physical illness, and injuries than those without ADHD. Despite having health care needs, children with ADHD were less likely than those without ADHD to use health care services. However, there were no significant associations between most health behaviors and ADHD. Conclusion: Increased efforts are needed to provide quality health care services to address the medical conditions of children with ADHD and to enhance their health care utilization when needed.

Physical-Mental Comorbidity of Pediatric Migraine in the Philadelphia Neurodevelopmental Cohort

OBJECTIVE

To examine the associations between headaches and migraine with physical and mental disorders in a large pediatric registry.

STUDY DESIGN

In total, 9329 youth aged 8-21 years from the Philadelphia Neurodevelopmental Cohort were included. Physical conditions, including headache, were ascertained from electronic medical records and in-person interviews. Modified International Classification of Headache Disorders (ICHD-II) criteria were used to classify migraine symptoms. Forty-two other physical conditions were classified into 14 classes of medical disorders. Mental disorders were assessed using an abbreviated version of the Kiddie-Schedule for Affective Disorders and Schizophrenia.

RESULTS

Lifetime prevalence of any headache was 45.5%, and of migraine was 22.6%. Any headache was associated with a broad range of physical disorders, attention-deficit/hyperactivity disorder (OR 1.2 [95% CI 1.1-1.4]), and behavior disorders (1.3 [1.1-1.5]). Youth with migraine had greater odds of specific physical conditions and mental disorders, including respiratory, neurologic/central nervous system, developmental, anxiety, behavior, and mood disorders than those with nonmigraine headache (OR ranged from 1.3 to 1.9).

CONCLUSIONS

Comorbidity between headaches with a range of physical conditions that have been associated with adult migraine demonstrates that multimorbidity occurs early in development. Comorbidity may be an important index of heterogeneity of migraine that can guide clinical management, genetic investigation, and future research on shared pathophysiology with other disorders.

Migraine and associated comorbidities are three times more frequent in children with ADHD and their mothers

OBJECTIVE

Attention deficit and hyperactivity disorder (ADHD) is a neuro-developmental disorder related to internalizing and externalizing disorders as well as somatic complaints and disorders. This study was conducted to evaluate the prevalence of headache subtypes, epilepsy, atopic disorders, motion sickness and recurrent abdominal pain among children and adolescents with ADHD and their parents.

METHODS

In a multi-center, cross-sectional, familial association study using case-control design, treatment naïve children and adolescents between 6 and 18 years of age diagnosed with ADHD according to the DSM-5 criteria as well as age- and gender-matched healthy controls and their parents were evaluated by a neurologist and analyzed accordingly.

RESULTS

117 children and adolescents with ADHD and 111 controls were included. Headache disorder diagnosis was common for both patients and healthy controls (59.0% vs. 37.8%), with a significantly elevated rate in the ADHD group (p = 0.002). Migraine was found in 26.0% of ADHD patients and 9.9% of healthy controls. Tension headache was found in 32.4% of ADHD patients and 27.9% of healthy controls. Headache diagnosis was also found to be significantly more common in mothers of children with ADHD than control group mothers (90.5% vs. 36.6%, p < 0.001).

CONCLUSION

Headache diagnoses and specifically migraines were significantly more common among children with ADHD and their mothers, while recurrent abdominal pain was elevated in both parents and ADHD patients. Migraine is an important part of ADHD comorbidity, not only for children but also for mothers. Motion sickness may be reduced among families of ADHD probands.

Gastrointestinal and Psychiatric Symptoms Among Children and Adolescents With Autism Spectrum Disorder

Individuals with autism spectrum disorder (ASD) are at heightened risk of psychiatric comorbidities across the lifespan, including elevated rates of internalizing, externalizing, and self-injurious behaviors. Identification of medical comorbidities that contribute to these concerns may elucidate mechanisms through which psychiatric concerns arise, as well as offer additional avenues for intervention. Gastrointestinal (GI) conditions are of particular interest, as they are prevalent among those with ASD, may share genetic or neurobiological etiologies with the core features of ASD, and are linked with psychiatric difficulties in the general population. In this paper, we draw on data from nearly 2,800 children and adolescents with ASD within the Simons Simplex Collection to characterize the unique contributions of (1) autism symptoms, (2) psychosocial factors (child's age, sex, verbal and nonverbal IQ, adaptive behavior, race, and household income), and (3) GI concerns with respect to multiple psychiatric outcomes. Multiple regression models revealed unique contributions of ASD symptoms and multiple psychosocial factors such as verbal IQ, adaptive behavior, and family income to internalizing, externalizing, and self-injurious behavior. In general, higher levels of psychiatric symptoms were associated with more ASD symptoms, higher verbal IQ, lower adaptive behavior skills, and lower family income. Furthermore, levels of GI symptoms accounted for unique variance in psychiatric outcomes over and above these other factors, linking increased GI problems with increased psychiatric symptoms in children with ASD. Taken together, results indicate that the presence and quantity of GI symptoms should be considered when evaluating psychiatric and behavioral concerns among children with ASD, and that treatment of GI conditions may be an important component in alleviating a broad array of mental health concerns in this group.

A Gut Feeling: A Hypothesis of the Role of the Microbiome in Attention-Deficit/Hyperactivity Disorders

Attention-deficit/hyperactivity disorder (ADHD) is a neurologic disorder characterized by hyperactivity/impulsivity and/or inattentiveness, with genetic and environmental factors contributing to the disorder. With the growing recognition of the microbiome’s role in many neurological disorders, the authors propose that it may also be implicated in ADHD. Here, we describe several evolving areas of research to support this hypothesis. First, a unique composition of gut bacteria has been identified and linked to behaviors in ADHD. Second, our research found an increased incidence of 2 gastrointestinal symptoms (constipation and flatulence) in children with ADHD, as compared to controls. Finally, emerging data may be interpreted to suggest that immune dysregulation in ADHD be associated with an altered microbiome, low-grade inflammation, and gastrointestinal dysfunction. Although more studies are needed to elucidate exact mechanisms and causality, we propose that an altered microbiome, gastrointestinal symptoms, and immune dysregulation may be associated with the ADHD phenotypes.

ADHD is associated with migraine: a systematic review and meta-analysis

An association between primary headaches and attention-deficit/hyperactivity disorder (ADHD) has long been suggested. Moreover, headache is regarded as a common side effect of stimulants, the most effective treatment for ADHD. So far, no systematic review has evaluated the potential association between ADHD and headache. We performed a systematic review of the literature and a meta-analysis of all reported studies on ADHD and primary headaches. Our analysis showed a positive association between ADHD and migraine (OR 1.322, 95% CI 1.018-1717, p value 0.036), but not with tension-type headache. There is a significant association between migraine and ADHD. The mechanisms underlying this association remain to be elucidated, warranting further studies.

Peripheral iron levels in children with attention-deficit hyperactivity disorder: a systematic review and meta-analysis

There is growing recognition that the risk of attention-deficit hyperactivity disorder (ADHD) in children may be influenced by micronutrient deficiencies, including iron. We conducted this meta-analysis to examine the association between ADHD and iron levels/iron deficiency (ID). We searched for the databases of the PubMed, ScienceDirect, Cochrane CENTRAL, and ClinicalTrials.gov up to August 9^th, 2017. Primary outcomes were differences in peripheral iron levels in children with ADHD versus healthy controls (HCs) and the severity of ADHD symptoms in children with/without ID (Hedges' g) and the pooled adjusted odds ratio (OR) of the association between ADHD and ID. Overall, seventeen articles met the inclusion criteria. Peripheral serum ferritin levels were significantly lower in ADHD children (children with ADHD = 1560, HCs = 4691, Hedges' g = -0.246, p = 0.013), but no significant difference in serum iron or transferrin levels. In addition, the severity of ADHD was significantly higher in the children with ID than those without ID (with ID = 79, without ID = 76, Hedges' g = 0.888, p = 0.002), and there was a significant association between ADHD and ID (OR = 1.636, p = 0.031). Our results suggest that ADHD is associated with lower serum ferritin levels and ID. Future longitudinal studies are required to confirm these associations and to elucidate potential mechanisms.