ADHD Comorbidity and Its Impact on Many Aspects of Development

#### **Chapter 4**

## Comorbidity in Children and Adolescents with ADHD

*Marija Burgić Radmanović and Sanela-Sanja Burgić*

#### **Abstract**

Attention Deficit Hyperactivity Disorder with or without hyperactivity disorder is a neurobiological disorder that involves the interaction of the neuroanatomical and neurotransmitter systems. It is a developmental disorder of psychomotor skills that is manifested by impaired attention, motor hyperactivity and impulsivity. This disorder is characterized by early onset, the association of hyperactive and poorly coordinated behavior with marked inattention and lack of perseverance in performing tasks; and this behavior occurs in all situations and persists over time. This disorder is inappropriate for the child's developmental age and maladaptive. Disorders of neurotransmitter metabolism in the brain with discrete neurological changes can lead to behavioral difficulties and other psychological problems. Most children and adolescents with Attention Deficit Hyperactivity Disorder have comorbidities, often multiple comorbid conditions in the same person. Comorbidity was observed in both clinical and epidemiological samples. It is estimated that about two-thirds of children with this disorder have at least one other psychiatric disorder diagnosed. Symptoms persist and lead to significant difficulties in the daily functioning of the child, such as school success, social interactions, family and social functioning, etc. Recent studies indicate the presence of various neuroophthalmological disorders in children and adolescents with ADHD. The most common comorbidities in children and adolescents with ADHD that will be covered in this chapter are autism spectrum disorder, mood disorder, anxiety, learning disabilities, conduct disorders, tics disorder and epilepsy.

**Keywords:** child, adolescent, ADHD, comorbidity, development

#### **1. Introduction**

ADHD is a neurobiological disorder that encompasses the specifics of neurotransmitter metabolism brain, and the interaction of the neuroanatomical and neurotransmitter systems. It is a developmental disorder of psychomotor skills that is manifested by impaired attention, motor hyperactivity and impulsivity [1]. Disorders of neurotransmitter metabolism in the brain with discrete neurological changes can lead to behavioral difficulties and other psychological problems. Behavioral disorders, secondary psychological problems, and interaction disorders with mild neurological symptoms may occur with this disorder [2]. To make a diagnosis, the symptoms must be frequent and severe than in children of comparable developmental level, and they must cause significant difficulties in the child's daily functioning [3]. It is a behavioral disorder that makes it difficult for a child to focus on daily requirements and routines. These children and adolescents usually have

difficulty organizing, focusing, making realistic plans, and thinking before they do something. The group of authors considers that ADHD is a developmental disorder of lack of behavioral inhibition, which manifests itself as a developmentally inappropriate degree of inattention, excessive activity and impulsivity, and complicates self-regulation and organization of behavior in relation to the future [4]. The main symptoms of ADHD are developmentally inappropriate for the age of the child and these are developmentally inappropriate levels of poor attention, hyperactivity and impulsivity. The degree of intensity of symptoms can vary according to the age of the child. Symptoms are manifested in the form of inattention of the child, the child does not perform its tasks, cannot organize, easily distracted, loses school and other things, "forgetful", avoids prolonged exertion.

The clinical picture in boys and girls differs in some aspects of the symptoms. Boys are more motor hyperactive and girls are more inattentive, as if "dreaming"; and their hyperactivity manifests itself as emotional and verbal (in the form of chatter, crying, etc.).

Data on the frequency of this disorder in developmental age differ depending on the applied methodology, age of the respondents, urban or rural region, number of persons providing data on the child's behavior (only parents, only teachers or both parents and teachers and others). Symptoms of hyperactivity are manifested in such a way that the child fidgets, gets up and leaves the bench, cannot play or do a task in peace, talks a lot, runs and climbs excessively, is always ready to "go" and others. Symptoms of impulsivity in a child are manifested by the child not being able to wait his turn, interrupting others when they speak, giving hasty answers, behaving intrusively and the like. Due to the symptoms, these children achieve poorer success in school, they have difficulties in mastering the school program, although they are most often of normal intellectual potential. Most adolescents who had ADHD as children still have difficulties in schooling, social interactions, and often emotional problems. Some adolescents may show irritability, poor school performance, disorganized learning, and poor communication with peers. ADHD always appears in early development, usually in the preschool period, and is most often noticed when a child starts school. This disorder usually lasts during schooling, and in some it continues into adulthood. Many people may experience improved activity and attention. Children with ADHD are often careless and impulsive so they are prone to accidents and injuries. These children often break the agreed rules and often have disciplinary difficulties. In relationships with adults, children with ADHD are often socially disinhibited, without caution and reserve, reckless behavior. Other children often avoid them, and are considered unpopular among peers, so they are often isolated.

The prevalence of ADHD is between 5 and 7% for children and between 3 and 5% for adults [5]. According to systematic review and meta-analysis, prevalence of ADHD among school-aged children and adolescent vary from 2.2% to 17.8% worldwide [6]. According to epidemiological studies, ADHD in children is thought to continue in 50–80% of cases in adolescence and adulthood. This high prevalence is of concern because this disorder negatively affects all neurodevelopmental areas and the psychosocial interactions of affected individuals. The risk may increase if symptoms such as aggression and irritability or comorbidities, such as behavioral disorders, are present.

In researching this problem, there are certain challenges in estimating the incidence of ADHD, such as are ways to assess ADHD, diagnostic methods, source of information about the disorder, agreement among respondents assessing ADHD symptoms, conducting assessments in one or more settings, age range of respondents, geographical location and characteristics of the community from which respondents originate [5].

Many studies indicate that ADHD is more common in boys [7]. The prevalence in boys and girls varies in different studies, and generally is more likely to be diagnosed and treated in boys than in girls [8]. The ratios from the clinical samples are higher than the ratios from the population samples. Research in this area of developmental psychiatry is extensive with a steady increase in the number of authors and professional literature dealing with this issue.

#### **2. Comorbidity**

The term "comorbidity" was introduced into medicine by Feinstein in 1970 to denote those cases in which a particular clinical entity exists simultaneously in a patient during the clinical course of his underlying disease [9]. Psychiatric disorders may coexist with somatic disorders and/or other psychiatric disorders when referring to "psychiatric comorbidity".

Different causes can lead to comorbidities, which can be accidental or the result of a combination of different risk factors; or two disorders may have the same or overlapping risk factors when one disorder causes the other; or there may be a multiform manifestation of one of the two basic disorders when the third - independent – occurs disorder. Due to insufficient knowledge of the etiopathogenesis of psychiatric disorders, modern classification systems (DSM and MKB) apply a descriptive, categorical system that classifies psychiatric symptoms and behaviors into a large number of different diagnoses.

The disadvantage of classification systems is that they poorly recognize the specifics and needs of child and adolescent psychiatry. The diagnostic process in developmental psychiatry is based on descriptive facts that determine the type of disorder, with the use of comorbidities to correct the shortcomings of this diagnostic process and to bring the diagnostic categories closer to the real clinical situation. These specifics are: symptomatic, developmental, environmental and prognostic. In developmental psychiatry, there are specific limitations in the external manifestation of symptoms, as well as in the possibility of insight into the existence of dependent symptoms. In child and adolescent psychiatry, there is the possibility of uneven development of basic developmental lines such as cognitive, emotional and social, especially during early childhood. In childhood, there is a clear dependence on past and current environmental conditions. Their interaction largely determines the manifestation of mental disorder at this age.

ADHD is one of the most common neurodevelopmental disorders in child and adolescent psychiatry and one of the most researched disorders in child psychiatry. Previous research indicates the existence of high comorbidity between ADHD and other psychiatric disorders in childhood. The presence of comorbidities largely depends on: case definition, assessment methodology, and control group. Studies have shown a high comorbidity between ADHD and behavioral disorders in the form of opposition and defiance, depression and anxiety. Some mechanisms for comorbidity include shared risk factors, distinct subtypes and weak causal relationships [10].

A 2015 study by Masi et al. showed more than 2/3 of patients with ADHD have a psychiatric disorder associated. The most common comorbid diagnoses with ADHD during early childhood are oppositional defiant disorder, enuresis and language disorder, and anxiety and tics in the mid-school years. In adolescence are observed mood disorder and substance use disorder. Many children with ADHD have a specific learning disorder [11]. The same study estimates that oppositional defiant disorder is concomitant with ADHD in 25–75% of the cases, conduct disorder about one third of cases, 6–30% of ADHD children have major depression,

#### *ADHD - From Etiology to Comorbidity*

more than 20% of bipolar disorder co-occur with ADHD; 87% of disruptive mood dysregulation disorder children had ADHD concomitantly; the prevalence of PTSD in children with ADHD is 5.2%; chronic tics disorder with ADHD is 55%; 85% of children with autistic spectrum disorder show a clinical picture of ADHD [11].

Barkley states that 67–80% of children diagnosed with ADHD who have been referred for clinical treatment have at least one more diagnosis, and almost half of them have two diagnoses [5]. Two-thirds of children with ADHD have at least one other psychiatric disorder diagnosed [12].

Some conditions occur more often than others. These are most often the following conditions:


The presence of comorbidities is significant because it complicates the diagnostic process, affects the course, prognosis and therapeutic process. Assessment and support in comorbid disorders are often as important as the assessment and treatment of ADHD symptoms [12].

#### **2.1 Comorbidity with behavioral disorders**

Behavioral disorders in developmental age are characterized by persistent and repetitive patterns of dissocial, aggressive, or defiant behavior. These behaviors in their most pronounced form can have criminogenic characteristics and deviate significantly from the socially expected ones according to the age of the child. These disorders are often accompanied by an unfavorable psychosocial environment, unsatisfactory family relationships and school failure. They are more commonly observed in boys than in girls.

Opposition-defiant behavior usually occurs in younger children, who exhibit extremely defiant, provocative, and disobedient behavior, and some children also exhibit aggressive behaviors. Most authors believe that 45–84% of children and adolescents with ADHD also exhibit oppositional-defiant behavior [5]. The

#### *Comorbidity in Children and Adolescents with ADHD DOI: http://dx.doi.org/10.5772/intechopen.94527*

Multimodal Treatment Study of ADHD found that about 62% of preschool children with ADHD and 59% of school children in the sample had oppositional-defiant behavior [5]. It is hypothesized that emotional dysregulation that occurs in children with ADHD may affect the occurrence of comorbidities for oppositional-defiant behavior, anxiety, depression, bipolar disorder, and other conditions, and it has also been observed that these children often have more psychopathology and social problems in the family [5]. These children are also at higher risk of taking various psychoactive substances, rejection from peers, poorer school achievement, rejection and the development of anxiety and depression in adolescence.

Many children with oppositional-defiant behavior also have conductive disorder, which is manifested by recurrent antisocial, aggressive, or defiant behavior. Study by Pliszka included 1035 children and adolescents at a psychiatric clinic and reported that 167 children and adolescents with ADHD were also diagnosed with oppositional defiant or conductive disorder [13]. Research demonstrated that 30–50% children with ADHD fulfill criteria for conduct disorder or oppositional defiant disorder [14]. These children are also at higher risk of substance abuse, antisocial activities, rejection from peers, school failure, anxiety and depression. The families of these children show more psychopathology and social problems.

#### **2.2 Comorbidity with specific learning difficulties**

These specific developmental disorders of school abilities include a group of disorders that are characterized by significant difficulties and impairments in mastering school skills, such as reading and arithmetic. These learning disabilities are not a direct result of other disorders such as mental retardation, neurological diseases, uncorrected vision or hearing disorders, or emotional disorders; although they may co-exist with them. Developmental disorders of school ability often exist in comorbidity with ADHD.

These disorders are thought to have arisen from abnormalities in cognitive processing that are mainly the result of some biological dysfunction; and are more common in boys than in girls. These children experience academic failure, often irregular schooling, difficulties in social adjustment and this is more pronounced in the later years of primary school or secondary school.

Specific learning difficulties are more common in people with ADHD than in the general population [15]. A meta-analysis of previous research has concluded that the prevalence is 45% [16]. These children have greater learning difficulties than children who have only specific learning difficulties.

Children with ADHD and specific learning difficulties have a problem processing perceived information, difficulty reproducing words, sentences and letters, auditory discrimination, difficulty reproducing drawings (visual-motor discrimination), stringing letters, decoding letters or words [2]. Children with this comorbidity will have lower academic achievement, poorer grades in school, will drop out of high school more often, and will continue their education after high school less often than their peers without ADHD [5].

#### **2.3 Comorbidity with mood disorders**

The main disorder in mood disorders is a change in mood or affect, in the sense of the presence of low mood or excessively good mood. A change in mood is usually accompanied by a change in the overall level of functioning. Most of these disorders show a tendency to recur. The onset of individual episodes is often associated with certain stressful events.

Children and adolescents diagnosed with ADHD often have mood disorders at the same time, most commonly having major depressive disorder, depressive episodes, and bipolar disorder. Arnold et al. conducted a Longitudinal Assessment of Manic Symptoms and concluded that 60% of the sample met the criteria for ADHD, 6.3% met the criteria for bipolar disorder, 16.5% had both ADHD and bipolar disorder. 17.5% do not have either of these two disorders [17]. Otherwise, the results of research in this area are uneven, so in population samples the prevalence is 0–2%, while in clinical samples it is 11–30% [18]. A special problem is the diagnosis, differential diagnosis and treatment in children who have ADHD and mania. ADHD is more common in children, especially in boys, compared with bipolar disorder, which occurs in 1.8% of children and adolescents, and is somewhat more common in boys [19]. Comparing the symptoms of mania and ADHD, a high percentage of grandiosity is noticeable in mania (85%), while in ADHD it is only 6.7%. Elevated mood and bold behaviors occur in a high percentage in mania (87% and 79%, respectively), and in a very low in children with ADHD. Results from regression analyses suggest cognitive predictors of executive functioning impairment in ADHD and mood predictors for inhibition in pediatric bipolar disorder [20].

Comparing the symptoms between these two diseases in childhood, it is noticed that irritability is very pronounced in mania, and occasionally exists in ADHD; euphoria is excessive in mania, and situational in ADHD; children with ADHD have low self-esteem, while mania has a pronounced grandiosity; manic children have a reduced need for sleep, while children with ADHD resist going to bed but then sleep well; children with mania have a rapid flow of thought, while ADHD does not. In comorbidity, treatment preference is given to symptoms of high mood and therapy is primarily focused on mania (mood stabilizers or antipsychotics); while ADHD symptoms are treated secondarily, after mood stabilization.

One of the mood disorders that occurs in child psychiatry is depression. Studies in this area indicate that the prevalence of depression in children with ADHD is 18%, and another 15% had both comorbid anxiety and depressive disorder [21]. The presence of depression worsens the symptoms and functioning of children with ADHD, and also significantly worsens the prognosis and therapeutic process in these children.

Adolescents who have a comorbidity of ADHD and depression have more pronounced difficulties in social functioning, get depression at an earlier age, have a higher rate of suicidal behavior, more frequent recurrence of depressive episodes compared to adolescents who suffer only from depression. Also, these adolescents have more frequent family dysfunction, more frequent conflicts in family relations, they have experienced more negative life events and traumatic experiences compared to adolescents who have only ADHD.

#### **2.4 Comorbidity with anxiety disorders**

The prevalence of anxiety disorders in the general pediatric population is between 4% and 20%, while the prevalence of anxiety disorders in children with ADHD is 25% [22]. Clinical and epidemiological studies have shown that one-third of children with ADHD have some of the anxiety disorders at the same time. While some authors believe that there is no statistically significant difference between girls and boys in ADHD comorbidity and anxiety disorder, other authors state that 17.6% of girls and 17.9% of boys have comorbid ADHD disease with anxiety or depressive disorder [8]. Children suffering from anxiety disorder have higher rates of ADHD [5].

#### **2.5 Comorbidity with the autism spectrum disorder (ASD)**

Autism spectrum disorder refers to serious developmental disorders with specific patterns of communication and social interactions. These disorders have differences in the specificity and severity of symptoms, age of onset, level of functioning, and forms of social interactions.

Autistic children often have attention problems and information processing problems that lead to social deficits. In clinical samples, it is estimated that about 10% of children tested for ADHD have some comorbid disorder from the autism spectrum disorder [9] characterized by more pronounced hyperactivity and impulsivity. ADHD is diagnosed in the autism spectrum disorder when the symptoms are very pronounced and permanent with the prior exclusion of medical and other psychiatric conditions that may mimic the symptoms of ADHD. In the treatment of ADHD comorbidities with autism spectrum disorder, the symptoms of both disorders must be treated.

#### **2.6 Comorbidity with specific developmental speech and language disorders**

In specific developmental disorders of speech and language, there is damage to the normal patterns of speech acquisition from the early stages of development. These disorders are often accompanied by associated problems such as reading difficulties and interpersonal relationships, emotional problems, and behavioral problems.

Some children who have ADHD also have language difficulties, which are present in both receptive and expressive language. There are also difficulties in other language skills. The results of research on the frequency of these comorbid diseases are different. Recent study estimated 50% of children with ADHD have a comorbid language deficit, while 20 to 60% of children with ADHD have one or more learning disabilities or language problems [23]. Study from 2016 identified language impairments in the majority within the ADHD and reading disorder in >40% in children with ADHD [24]. A group of authors concluded in a 2013 study that children with ADHD exhibit various difficulties in pragmatic language [25].

#### **2.7 Comorbidity with epilepsy**

Epilepsy is a chronic brain disease characterized by recurrent epileptic seizures, accompanied by various clinical manifestations and laboratory abnormalities. Important features of epilepsy are chronicity and recurrence of excessive paroxysmal discharge of brain neurons that manifest as epileptic seizures.

Studies in children with ADHD have shown a significant risk of developing epilepsy and other seizures in these children. A study by a group of Norwegian authors in 2013 found that children with ADHD had 2.3% risk of epilepsy, which is four times higher than the general prevalence in children of 0.5% [26]. Previous research has also found a significant association between childhood ADHD and the risk of epilepsy. Epilepsy and ADHD are strongly associated although the underlying factors contributing to their co-occurrence remain unclear [27]. The same study suggests that epilepsy and ADHD share less genetic risk factors as compared with other neurodevelopmental disorders.

Children with ADHD often have irregularities in EEG findings, and an increase in frontal-central theta-wave activity is most common [28].

#### **2.8 Comorbidity with sleep disorders**

Inorganic sleep disorders can also occur in children of any age. The most common sleep disorder in children is a sleep–wake cycle disorder, i.e. waking up during the night. This is also the most common reason that worries parents and why they seek professional help. The next most common disorder is when the child delays going to bed, cannot fall asleep when put to bed or when constantly asking for parental attention. Other sleep disorders are less common in children.

Children with ADHD often have difficulty sleeping in the form of frequent waking at night, resistance to going to sleep, they need to fall asleep for a long time. Sleep disorders are more likely to occur if children with ADHD also have some anxiety disorder compared to children who have only ADHD [29]. In observational study in a population of children with ADHD, 63% had moderate or severe sleep problems [30].

Parents of children with ADHD also report that children have difficulty sleeping, resist going to bed, sleep shorter, and often wake up at night. Parents describe these children as tired after waking up compared to children without ADHD [31]. Studies investigating event–related potential (ERP) suggest impaired ability in children with ADHD to conserve the brain oscillations phase associated with stimulus processing [32]. Children with ADHD presented more sleep disturbances when compared to children without the diagnosis. These disorders were diverse, yet inconsistent among the surveys [33].

#### **2.9 Comorbidity with tic**

Tic is a sudden, fast, involuntary, aimless and repetitive muscle movement, limited to a certain muscle group or accompanied by vocalization, which worsens in stressful situations and disappears during sleep. Tic disorders are divided into transient and chronic motor or vocal and Tourette's syndrome. There is an irresistible need to repeat the action, and its prevention causes tension. Tick disorders are associated with poor self-esteem, problems in the family environment, difficulties at school. Children and adolescents with tics have a number of other problems such as speech or behavior problems, impulsivity, hyperactivity, obsessive compulsive symptoms. The prevalence of transient and simple tics is 20% in the pediatric population, and chronic motor tics and Tourette's syndrome about 3% [34]. Children with ADHD were 4.1 times more likely to have chronic tic disorder at age 7, and 5.9 times more likely at age 10 [35]. Children with ADHD and chronic tic disorder experienced higher rates of peer problems, and poorer quality of life than those with ADHD alone. Episodes of anger and aggression have been reported in children with tic disorders and are likely to contribute to psychosocial stress and low quality of life. It is assumed that aggressive behavior in children with tic disorders is associated with comorbid attention-deficit hyperactivity disorder [36].

#### **2.10 Comorbidity with neuroophthalmological disorders**

Ophthalmological examination of children and adolescents with ADHD is part of their evaluation as it is important to rule out underlaying ocular and neurological conditions that may cause behavioral aberrations. Some children with visual impairment may be misdiagnosed as ADHD. These children are not able to see adequately and in result are not able to keep their attention being focused on object of observation. To our knowledge, there are small number of studies investigating the relationship between ADHD and ocular disorders such as amblyopia, hypermetropia, astigmatism, and heterotropia. Children with amblyopia have greater risk

*Comorbidity in Children and Adolescents with ADHD DOI: http://dx.doi.org/10.5772/intechopen.94527*

of developing ADHD than their counterparts without amblyopia (1,8 times; hazard ratio 1.81; 95% confidence interval 1.59–2.06) with the greatest risk in amblyopic children with deprivation type, followed by strabismic type and refractive type (hazard ratio 2.14; 95% confidence interval 1.56–2.92; hazard ratio 2.09; 95% confidence interval 1.15–3.79; hazard ratio 1.76; 95% confidence interval 1.54–2.02 respectively). Also, amblyopic children with ADHD tend to be diagnosed at younger age than those without amblyopia (median 8.14 vs. 8.45years; P = 0.0096) [37].

Large cross-sectional study on 75,171 children without any intellectual impairment reported greater prevalence of ADHD among children with vision problems (p < 0.0001). Children with vision problems were more likely to have been diagnosed with ADHD than those without vision problems (15.6% vs. 8.3%; p < 0.001). Children with vision problems were also more likely to have ever been diagnosed with ADHD (18.6% vs. 10.4%; p < 0.001) [38].

Another large-scale cross-sectional study on 116,308 children with ADHD reported significant higher prevalence of ocular disorder in children with ADHD compared to children without ADHD: amblyopia (1.6% vs. 0.9%, p < 0.001), hypermetropia (2.4% vs. 1.3%, p < 0.001), astigmatism (0.2% vs. 0.1%, p < 0.001), and heterotropia (1.1% vs. 0.5%, p < 0.001) respectively [39].

Recent studies investigated relationship between ADHD and convergence insufficiency as symptoms of convergence insufficiency may overlap with those of ADHD. Within population of children with convergence insufficiency, three-fold greater incidence of ADHD is reported compared to ADHD incidence in general population. Also ADHD population had three-fold greater incidence of convergence insufficiency [40]. Children with ADHD had significant low near point convergence as well [41].

#### **2.11 Treatment of comorbidities**

Comorbid diseases often occur in children and adolescents with ADHD. It is estimated that about 66% of ADHD patients have at least one comorbid disorder, and the most common are learning disorders, sleep disorders, oppositional defiant disorder and anxiety disorders [42]. Treating children and adolescents with ADHD who have comorbid conditions is a challenge for clinicians [43].

When it is necessary to include medications in children with ADHD, existing guidelines suggest starting with a stimulant (methylphenidate MPH or amphetamine AMP). If the stimulant does not achieve an effect then an alternative stimulant is used. If stimulants are not effective or cause more severe side effects, we include nonstimulants (atomoxetine, alpha-2 agonists, and antidepressants) [44]. Stimulants have been approved by the Food and Drug Administration (FDA) in the treatment of ADHD, including methylphenidate and dextroamphetamine and amphetamine mixed salts, and these drugs act by blocking the reuptake of dopamine and norepinephrine into neurons. Side effects including insomnia, headache, changes in appetite, weight loss/gain, irritability and tics should be monitored during treatment with stimulants. Stimulants are the first line in treatment. Non-stimulants (atomoxetine, alpha-2 agonists, and antidepressants) are less effective than stimulants. Children with complicated epilepsy may be at greater risk for ADHD, and some antiepileptic medications may contribute to ADHD symptoms. Tricyclic antidepressants have been used in children with ADHD but can lower seizure threshold and should be avoided in patients with epilepsy. Methylphenidate is effective in treating the symptoms of ADHD in children and adolescents with epilepsy, but the effectiveness is less than that seen in children with ADHD without epilepsy [44].

The comorbidity of ADHD with bipolar disorder (BD) may be associated with more severe symptoms, poorer course, and poor outcome of both conditions, and treatment is further complicated if there is substance abuse [45]. The use of stimulants may be contraindicated in the presence of comorbid drug abuse. Atomoxetine may be effective in treating the symptoms of ADHD in patients with bipolar disorder when used in conjunction with mood stabilizers.

In children with ADHD comorbidities and sleep problems, sleep hygiene and cognitive-behavioral psychotherapy are important, and consideration should be given to changing the dosage and formulation of the stimulant. The use of atomoxetine and melatonin are therapeutic alternatives for children with ADHD and more severe sleep problems [46].

Psychopharmacology is the primary treatment for ADHD, and behavioral treatment is used in combination with medication or in children with minimal impairment or when medication is not possible due to contraindications or parents 'refusal to accept medication. Most guidelines recommend a stepwise approach to treatment, beginning with non-drug interventions and then moving to pharmacological treatment in those most severely affected [47]. In large birth cohort study, where a great majority of children with ADHD used medication, only child characteristics were significantly associated with the use of medication [48]. In this study the authors concluded that the small differences between medicated and unmedicated children, might be due to strong established clinical practices where medication is offered as a treatment option, particularly for hyperkinetic conduct disorder in an egalitarian high-income society.

In a large meta-analysis that included 38 individual studies with 5111 participants aged 3 to 18 years, the authors concluded that methylphenidate may improve teacher-reported ADHD symptoms, teacher-reported general behavior, and parent-reported quality of life among children and adolescents diagnosed with ADHD [49].

Treatment of comorbid diseases in children with ADHD should be multimodal, including pharmacological and nonpharmacological interventions. It is important to recognize the presence of comorbid disease in these children because comorbid diseases complicate the diagnostic and therapeutic process, as well as the outcome of the disease.

#### **3. Conclusion**

Attention Deficit Hyperactivity Disorder is a neurobiological disorder that involves the interaction of the neuroanatomical and neurotransmitter systems. This disorder is characterized by early onset, the association of hyperactive and poorly coordinated behavior with marked inattention and lack of perseverance in performing tasks; and this behavior occurs in all situations and persists over time. Most children and adolescents with Attention Deficit Hyperactivity Disorder have comorbidities, often multiple comorbid conditions in the same person. It is estimated that about two-thirds of children with this disorder have at least one other psychiatric disorder diagnosed. Symptoms persist and lead to significant difficulties in the daily functioning of the child, such as school success, social interactions, family and social functioning. The presence of comorbidities is significant because it complicates the diagnostic process, affects the course, prognosis and therapeutic process. Assessment and support in comorbid disorders are often as important as the assessment and treatment of ADHD symptoms.

#### **Conflict of interest**

The authors declare no conflict of interest.

*Comorbidity in Children and Adolescents with ADHD DOI: http://dx.doi.org/10.5772/intechopen.94527*

### **Author details**

Marija Burgić Radmanović1 \* and Sanela-Sanja Burgić2,3

1 Department for Child and Adolescent Psychiatry, University Clinical Center of Republic of Srpska, Banja Luka, Bosnia and Herzegovina

2 Eye Clinic, University Clinical Center of Republic of Srpska, Banja Luka, Bosnia and Herzegovina

3 University of Banja Luka, Faculty of Medicine, Banja Luka, Bosnia and Herzegovina

\*Address all correspondence to: marija.burgic-radmanovic@med.unibl.org

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## **Chapter 5** ADHD and Impact on Language

*Clay Brites*

### **Abstract**

The language problem in ADHD could be expressed in any age, in different intensity levels, that could bring negative effects in all daily activities and learning process, which depends on the right language acquisition during the child's development. Among the most common comorbidities in ADHD, the abnormalities in language result in greater unsatisfactory evolution and many problems in verbal and nonverbal abilities, and even more in academic life, as a result of losses in reading and writing appropriation.

**Keywords:** comorbitidy language, ADHD, language, cognitive processing, neuropsychological assessment

### **1. Introduction**

The attention deficit hyperactivity disorder (ADHD) is a neurobiological condition, which starts in childhood and youth phase, derived of genetics and external factors, that features an attention, hyperactivity, and impulsivity deficit excess [1]. It hits worldwide an average of 6–10% of children and 2.5–4% of adults [1, 2]. It also causes emotional self-regulation problems, executive impairment, and space and motor disorganization and may cause language problems in 30–40% of the cases [3].

The language problem in ADHD could be expressed in any age, in different intensity levels, that could bring negative effects in all daily activities and learning process, which depends on the right language acquisition during the child's development. Among the most common comorbidities in ADHD, the abnormalities in language result in greater unsatisfactory evolution and many problems in verbal and nonverbal abilities, and even more in academic life, as a result of losses in reading and writing appropriation [4].

Thus, it is essential to understand the facts that interrelate ADHD with the cognitive and language development process, or particularly where and how ADHD neurobiological dysfunctions affect the dynamic of the neural network responsible for the receptive, integrative, and expressive language structure in different child neurodevelopment levels.

#### **2. The neurobiological aspects of ADHD**

ADHD leads to emotional and cognitive self-regulation problems, which affect the executive attention and operational memory in the performance of discretionary, routine, and habitual activities. Tasks with no immediate reward which are, at the same time, necessary, priority, and essential for the development of basic abilities and general learning, adding the capacity of self-engage for whole process conclusions [5].

The cause of this disorder is still unknown but is generated by the interaction between genetic and environmental factors (**Table 1**) and by similar epigenetics mechanisms in neuropsychiatry diseases, and they are caused by polygenic inheritances of irregular transmission and are influenced by the environmental and gender predispositions. In the case of ADHD, the predominance is male, in the ratio of 4:1 [6]. So even without a specific cause, these abovementioned data in conjunction with epidemiological evidence provide to the specialists and international consensus a safe outline to the genetic and environmental risk factors for ADHD development (**Table 1**) [7]. The knowledge about these factors contributes for the clinical surveillance during early childhood in order to observe the possibility of the appearance of the first symptoms, adolescence, and adulthood.

The symptoms and cognitive-behavioral changes of ADHD are the results of abnormalities in several neuronal connections, both cortical and subcortical, which can lead to functional impairments in one or more brain regions at the same time. The most affected and described connections mainly involve the anterior cingulate gyrus, prefrontal cortex, amygdala, striatum, and ventral integumentary area, that is, both voluntary and involuntary regions of attention that regulate the intensity and support of the attentional focus [8]. These regions are interconnected by the action of dopaminergic and noradrenergic neurotransmitters, and their deficits also contribute to lowering the attentional functional of ADHD. Added to them are the maturational delays that can gradually occur in these connections during the first years of life and which are observed in many research-based evidences in the functional neuroimaging of the brains of children with ADHD when compared to typical children. The pace of neuronal and connective maturation is slower, erratic, diffuse, or delimited and can emerge clinically at different times in the life cycle, from early childhood to late adolescence [8, 9].

Neuroimaging exams, much more developed today because of the technological advances associated with neuroscientific research, such as functional magnetic resonance imaging (fMRI), are able to analyze the maturational dissonance present in groups with ADHD from a comparative perspective with case controls. There are also brain morphometry, cortical thickness index, diffusion images (tractography), surface measurements of brain areas, gyration index, and geodetic mapping. These methods have shown that ADHD leads to microstructural changes and modifies the proportions between the functional regions of the brain [10, 11].


#### **Table 1.**

*Genetics and environments risk factors for ADHD clinical features.*

Thus, the various changes present in ADHD can be summarized as dismaturationals, connectives and productive, and abnormal bioavailability of neurotransmitters in the cortical (top-bottom) and subcortical (bottom-up) networks.

#### **3. Neuropsychological and endophenotypical behavioral aspects of ADHD**

If we have a different and inefficient brain to process information, the next question would be: In what and how would it be different? In what functional aspects? What neuropsychological deficits are predominantly present in ADHD?

As there are still no specific biological markers, the description and clinical definition of ADHD is based on the *Diagnostic and Statistical Manual of Mental Disorders* (*DSM-5*) criteria (**Figure 1**) on neuropsychological assessments and on the construction, since the early 2000s, of possible candidate profiles to be its endophenotypes [8, 12]. These parameters help to establish the diagnosis and understand its functional deficits.

ADHD can lead to three major functional deficits: (1) executive attention deficit, (2) operational memory problems, and (3) self-engagement in sequential tasks without reward [13].

**Executive attention** is responsible for the ability to increase the degree of sensitivity, directing the brain perceptions, and persisting in these analyses, being able to verify the details and the most significant information of any task. It includes selective, sustained, alternating, divided, covered, and spatial attention and is able to manage focal points according to time, space, and priorities. It depends on the connection integrity of frontal areas with the anterior and striated (subcortical) cingulate regions.

**Operational/working memory** is the ability to immediately memorize sequential information to fully accomplish it without forgetting the most important, decisive priority details and those that require data from other axes of knowledge, seeking to align them with those already memorized. It depends on the integrity of frontal regions with amygdala-hippocampus-striatal connections.

**Self-engagement in sequential tasks without reward** is the "energetic" amount of self-effort and intention undertook to fully and correctly fulfill a specific activity, task, or request without a greater motivation, or which represents a routine, rule, or command by an authority or institution. We can also call it cognitive selfregulation and it depends on connections between regions of the prefrontal cortex with the striatum, ventral regions of the anterior cingulate cortex, amygdala, and ventral tegmental nucleus.

The ADHD patient has a deficit in these three abilities and, therefore, the presentation of its clinical condition and functional difficulties are predominantly concentrated in executive functions, problems in working memory (verbal and nonverbal), difficulties in executive attention, and insufficient surveillance to fulfill correctly activities without immediate attractiveness or pleasure. Even though these characteristics are well defined, there is still no single endophenotypic pattern for ADHD or a neuropsychological profile. However, this evidence is sufficient to better understand the diagnostic approach in clinical suspicion, which evaluation methods to request, and in interdisciplinary evaluations, how to understand the deficits and discrepancies present in each of them and to associate with the main complaints of the child and the child's school.

Thus, in the neuropsychological evaluation, we have to use the instruments that can measure selective and sustained attention, executive functions, verbal and




#### **Figure 1.**

*ADHD DSM-5 criteria. Source: Refs. [18, 19].*

nonverbal working memory, reaction time, and cognitive flexibility. Furthermore, correlate these assessed skills with the behavior of the assessed person during the exam, their reactions, avoidances, profile of behavioral responses to failure and test prolongation, etc. The description of these behaviors should be part of the feedback for the specialized team and will be useful for the conclusions.

#### **4. The impact of ADHD on language neurodevelopment in childhood and school**

After it all, and the language? The child's learning, from a young age, in the early years, depends on several factors and, neurobiologically, in his first contact with the world, he needs his sensory and perceptual functions. Vision, hearing, touch, etc. and its perceptual centers in the brain added to the qualitative perceptual functions as well, such as attention and memory, to correctly absorb and fix the selected stimuli in the brain. Language, in this context, results from its innate abilities (presence of a network and integral structure for the language) and the internalization of the "languages" perceived around it. Little is known yet whether ADHD affects more innate or acquired language, but in several comparative studies associating both conditions, it appears that ADHD influences the appearance of language disorders (LDs) much more than the opposite [14, 15]. There are sufficient data demonstrating that, in groups of children with LD, there are proportionally fewer children with ADHD than when evaluating groups of ADHD seeking to verify the presence of LD [16].

The adequate construction and the full development of language structuring processes in childhood depend heavily on attentional, executive, and working memory processes. The union of all these factors in the construction of language can be understood by several psychological theories and theoretical constructs, but it is well summarized in the **phonological buffer** [15, 17, 18]. In language science, the phonological buffer is a neurobiological and cognitive mechanism of language composed of skills that align and influence each other as a dynamics of weights and balances for the perception, memorization, and integration of linguistic sensory stimuli contributing to the development and consolidation, in memory, of processes associated with language structures in a coherent way. Consolidated, this same buffer triggers the emergence of previously selected and memorized phonological data to be used for a given expressive activity in an organized and sequential manner (speaking, reading, writing, etc.).

The skills that make up the buffer are executive attention, working memory, and phonological awareness (**Figure 2**). Among the three, the first two are functions specifically associated with ADHD. In ADHD, both are deficient, unstable, and functionally oscillating and end up negatively influencing the development of speech and language in the early years of life, which are skills that depend on phonological awareness and therefore affect the cognitive processes of language.

#### **Figure 2.**

*Interrelation among executive attention, working memory, and phonological awareness to building reading and writing.*

In this context, it seems that the selective and sustained attentional deficit would be the main center of disfunction. Attention selectively focuses on one aspect of information and excludes the other. The child who is learning the language from an early age must be able to selectively focus on relevant linguistic information and naturally ignore irrelevant information. He/she must sustain this focus to form an association between an object and a label in the word learning process. When the input source of the language or object changes, the child must also be able to draw attention away to avoid losing relevant information. As language develops, he/she must be able to attend linguistic sequences and social routines for the development of grammatical and pragmatic skills. If he/she cannot do this, whether due to attention deficits or early language problems, the process of language acquisition and consolidation will be fragmented and deficient.

There are also other factors that associate ADHD with language from a genetic and developmental point of view. Children with ADHD may have, in up to 40% of cases, speech development delays because it can affect the perception of sounds during the speech of his peers and caregivers, generate joint problems, and increase chance of stuttering; and by forming phonemes and syllable junction, it is possible to observe a greater slowness in syllabic awareness in these patients [19]. This means the disorder affects attention, motor control (inhibitory and rhythm), and working memory, eventually leading the referred gaps in the evolution of the articulatory and phonological organization.

Another factor described would be the presence of mutations and other genetic abnormalities between both conditions, which would lead to the transmission of their deficits present in the parent(s) to their children. And, finally, the separated association of both conditions that were generated in the same child without one being incidental to the other, but both sharing dysfunctions in specific areas in their interaction, participating in reading and writing language-related functions and language structure [20].

#### **5. Aspects of language influenced by ADHD**

Several publications and researches show language alterations in ADHD patients [21]. There is still a need for greater research about the genetic or environmental factors involved. Some evidence describing genes that appear to be at the interface of both conditions already exists, such as FOX2 and CNTNAP2 [22]. But they still lack models that really demonstrate the solid link between them, what kind of comorbidity is included, and what genetic relationships exist (and, specifically, with which genes or mutations). For now, the most common studies are based on relative risk measures (RRs) and odds ratio (OR), and in these, they observe risks of two to six times greater language problems in ADHD groups when compared to controls [19].

ADHD can affect four axes of language in childhood and adolescence: (1) delays in speech acquisition and language structuring (mainly articulatory, phonological, lexical, and morphosyntactical but also, in a second plane, pragmatical); (2) hearing processing disorders; (3) abnormalities in speech (speech, voice, and fluency); and (4) deficits in the linguistic processes involved in the appropriation of reading and writing and math learning (**Table 2**).

In research conducted with 76 children with ADHD and an average age of 11 years old, Bruce e cols. (2006) observed that more than half of them were accompanied by a speech therapist and the rest did not receive any intervention. The results showed that most children had problems in pragmatic language, language comprehension with greater receptive communication deficits and delays, and learning gaps in reading and writing. In this same work, cognitive tests were carried


#### **Table 2.**

*Four axes of language in childhood and adolescence affected for ADHD.*

out and the evidence showed that the pragmatic losses were due to the inattention and impulsive behavior of ADHD [23]. There are at least seven ADHD symptoms present in the *DSM-5*, which are indicative of problems associated with communication and language: (1) does not seem to hear when talking directly to him/ her; (2) difficulty in carefully following instructions; (3) rush to answer before the questions are even finished; (4) interrupts or intrudes on the conversation of others; (5) difficulty in waiting for dialog shifts; (6) speaks excessively and without selfcontrol; and (7) difficulty in playing silently. Such symptoms have a major negative influence on the construction of communication skills, which can be consolidated during child development and adolescence and remain altered throughout life [2].

Besides, the existence of speech delay, articulatory problems, and stutter are relatively frequent in ADHD. Researches show that 25–40% of the cases suffer from such alterations and that indicates possible harm in complex acquisition with aging until it becomes predisposed comorbidity with dyslexia [24]. Many children with ADHD need speech therapy in their early ages of life, and a great part of them keep the therapy until the beginning of school and literacy years, but demonstrations show that with early intervention, the prognostic can get much better [25]. Pieces of evidence show larger deficits in the phonological and articulatory abilities, semantic structure, vocabulary repertoire, reading comprehension, and pragmatic process during dialogs and discursive abilities [26, 27].

The hearing processing is a set of specific and nonspecific skills associated with the set of skills necessary for an adequate perception, integration, and interpretation of what is heard in the most diverse environments. ADHD, due to its characteristics, especially affects the nonspecific skills necessary for auditory processing: the integrative, temporal, and organizational aspects of auditory discrimination. Almost 50% of cases of auditory processing disorders have comorbid symptoms of ADHD and their treatment requires intervention in both for good results to occur [28, 29].

Regarding discursive skills, several changes are observed in people with ADHD. Problems in sustained attention, impulsiveness to conclude and accelerate the discursive times and attentional lack of control, and seeming not to hear the interlocutor make these patients have greater difficulty in applying the right words and expressions at the right time and with plausible intentionality. Through it away occurs both to listening and delivering speeches and, especially, in the consistent persistence of the records heard, they show sudden and erratic self-distractions,

little perception for moments of exclamations and tangential comments, hum and make strange noises during the process, enters with new topics decontextualized, and have little sensitivity to perceive commotions during the speech [2]. These difficulties can lead to great losses in the classroom, in lectures, in the coordination of speeches during a comment, and in the correct and strict understanding of a dialog or a recommendation or even "scolding" or warnings from your parents or caregivers. Perhaps, this explains why these patients tend to repeat the same mistakes or do not understand small insinuations or messages contained in the speeches that they hear and receive severe and repeated criticisms in social relations for this.

The significant problems and deficits observed in the processes of learning to read and write and, even later, in the literacy phase and in the already consolidated phase of the acquisition of these skills in these patients are varied and numerous—and today well described—in the scientific literature. People with ADHD have delays and gaps in the process of acquiring and appropriating basic skills for learning to read and write in up to 30–40% of cases. We see little memorization of graphic and phonemic symbols, difficulty in joining letters, and graphophonemic decoding. They usually forget much of what they saw or heard in class and can evolve greater irregularity so that they will acquire the proper fluency and automatic word recognition, sentences negatively affecting the ability to interpret, assimilate statements, and produce texts coherently. They may have more difficulty in organizing the words and phrases sequentially and "lose themselves" in the cohesion of the set of information they write in addition to often not being able to remember all the significant details to clarify an argument in writing.

Not being able to remember orthographic rules or perceive prosodic circumstances in the text to properly apply punctuation or paragraphs are constant in ADHD and can damage the semantic-pragmatic nexus. The longer and subliminal the writings, the greater the difficulties in textual praxis and the subsequent errors. Not to mention the problems of graphomotor coordination generated by the problems of rhythm, persistence, and inhibiting self-control of manual writing mobility, which in addition to deteriorating handwriting, leads to early tiredness, pain in the limb, and aversion/displeasure toward writing. They do not even take care of their writing tools because they lose, break, and play more with them in their hands. By making use of them at the time of class, they confusingly drop, destroy, and barely manage to stay at your desk during the class period. Furthermore, as they usually strain to perform in a less productive/in-depth manner than their colleagues, their text ends elementary, without details, abbreviated, saving words and, even so, they think what they have done is great and "enough"; but, actually, it had resulted in an insufficient work that is poorly done and that had to be corrected. Persistent, recurring delays lead to a progressive inadequate acquisition of skills and many of these young people progress to learning disorders [19].

All of this evidence can help to understand why ADHD patients act socially more with their hands (by actions) than with their eyes and mouth (by structuring words and arguments) and then being less assertive, wordy, and emotionally loosely organized in social interaction. Not to mention the significant losses in school performance, poor interpretation of statements, and low self-esteem for academic processes. The risk of school failures and dropouts is four times higher in these patients and reduces the chance of completing and receiving a university degree by up to eight times [30, 31].

Finally, the knowledge about these changes by health and education professionals is very important because the effects on the global development of the child's language will lead to a negative, progressive impact in all related areas. The severe appearance of gaps in school learning, in the understanding of verbal and nonverbal processes of social communication, and the emotional and affective

relationships that depend on language skills can lead to subjective problems in the patient and in family dynamics with different impacts throughout his life.

### **6. ADHD and language: The role of speech therapy**

In the face of all the observations and the aforementioned evidence, the hearing care professional should be prepared to evaluate these children. Delays in speech and language acquisition should always suggest the possibility of ADHD as well as the presence of quantitative and qualitative deficits in BP, speech skills, and reading and writing, depending on the chronological age. However, studies and publications on ADHD and aspects related to language around the world still lack, except on the area of reading, which is the only one with more robust studies [32].

There is still no protocol or consensual or systematic recommendations on how the speech therapist can act in this area. However, there are articles and publications that can help this professional to create a basic protocol to better direct their work and to assist in a complementary, more refined, and objective way for the interdisciplinary team in order to better conclude the diagnosis and more broadly direct future strategies' therapeutic [32, 33].

Even so, some recommendations can help, right now, to improve the procedures of speech therapy assessment in ADHD:



#### **Table 3.**

*Instruments in speech therapy for language assessment in ADHD.*


### **7. Final considerations**

Knowing the aspects of ADHD related to the development, structuring and school management of language is essential for undertaking an adequate assessment of these patients during and after the diagnostic process. During, in order to decisively contribute to speech therapy data in the confirmation of a further condition without definitive biomarkers. After, in order to delineate with the results the treatment needs that may involve the speech therapist, who has the role of intensively intervening in deficits that are not within the competence of the school or family but should be corrected by the specialist in order to provide a more favorable and persevering school performance.

### **Author details**

Clay Brites Neurosaber Institute, Londrina, Paraná, Brazil

\*Address all correspondence to: claybrites@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### *ADHD and Impact on Language DOI: http://dx.doi.org/10.5772/intechopen.93541*

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#### **Chapter 6**
