Eur Child Adolesc Psychiatry [Suppl 1]

13:I/80–I/92 (2004) DOI 10.1007/s00787-004-1008-4 ORIGINAL CONTRIBUTION

Christopher Gillberg Co-existing disorders in ADHD –

I. Carina Gillberg
Peder Rasmussen implications for diagnosis
Björn Kadesjö
Henrik Söderström and intervention
Mania Råstam
Mato Johnson
Aribert Rothenberger
Lena Niklasson

■ Abstract Background It is only
recently that “comorbidity” in
ADHD has come to the forefront as
Prof. C. Gillberg (
) · I. C. Gillberg ·
P. Rasmussen · B. Kadesjö · H. Söderström ·
M. Råstam · M. Johnson · L. Niklasson
Göteborg University
Dept. of Child & Adolescent Psychiatry
Kungsgatan 12
41119 Göteborg, Sweden
E-Mail: christopher.gillberg@pediat.gu.se
A. Rothenberger
Child and Adolescent Psychiatry
Göttingen University
Göttingen, Germany
one of the most important aspects
of the disorder. It is agreed that, of-
ten, these problems are at least as
important as ADHD in contribut-
ing to the longer term outcome in
the individual child. Objective To
provide the reader with basic infor-
mation about clinics and treatment
of “comorbidity” in ADHD. Method
Review of the empirically based lit-
erature. Results ADHD exists in a
surprisingly high frequency to-
gether with a broad range of child
neuropsychiatric disorders. This is
accompanied with many still unre-
solved treatment problems. Conclu-
sion It would not be appropriate to
develop ADHD-services where
clinicians would only have exper-
tise in ADHD as such. Anyone
working with children, adolescents
and adults with ADHD would need
to have training in general neu-
ropsychiatry. Further research in
this field is urgently needed.
■ Key words ADHD – children –
comorbidity – diagnosis –
treatment – review

with morbid conditions, i. e. diseases. In actual fact, the

Introduction
ADHD is one of the most prevalent disorders of child-
hood [32]. It is associated with long-term psychosocial
consequences in a majority of cases [12, 66, 105]. How-
ever,it is far from clear what it is that drives the poor out-
come: ADHD per se or one or more of the very frequent
co-existing disorders.
It is only fairly recently that “comorbidity” in ADHD
has come to the forefront as one of the most important
aspects of the disorder [17, 63, 64]. The word comorbid-
ity is misleading in at least two different ways. First, clin-
icians of various kinds and researchers from different
fields tend to disagree on the meaning of the word. Some
take “comorbidity” to mean that a common underlying
etiology leads on to two or more different disorders.
Others consider it to be a matter of one disorder leading
to another.Yet others suggest that “comorbidity” is pres-
ECAP 1008
vast majority of problems/peculiarities listed as “comor-
bid” are not disease entities1, but represent conditions,
functional impairments and symptom constellations
whose clustering together are not rooted in specific dis-
eases. Therefore, the word comorbid will be used spar-
ingly in this paper, and reference will instead be made to
“co-existing” disorders and problems.
The first population study of a broad spectrum of co-
existing disorders in children with attention deficit dis-
order (ADD) – corresponding to ADHD in about 85 % of
cases [105] – was published 20 years ago [43]. The report
highlighted the extremely high rate of associated disor-
ders in ADD, particularly motor-perception dysfunction
(nowadays referred to as developmental coordination
disorder or DCD), depression and anxiety disorders, op-
1 Recently this issue was raised again concerning ADHD by findings
of Jensen et al. [64], which indicated that three clinical profiles

ent only when two clearly separate disorders, unlinked (ADHD + Anxiety; ADHD + ODD/CD; ADHD + Anxiety + ODD/
etiologically or sequentially, occur together [18]. Sec- CD) may be sufficiently distinct to warrant classification as ADHD
ond, the word “comorbid” implies that we are dealing subtypes different from “pure” ADHD with neither comorbidity.
 C. Gillberg et al.
Co-existing disorders in ADHD – implications for diagnosis and intervention
positional and conduct problems and autistic features
(now commonly referred to as autism spectrum disor-
ders (ASD) or pervasive developmental disorders not
otherwise specified or PDDNOS). This study was not fol-
lowed by a considerable body of evidence regarding as-
sociated problems in ADHD until more than a decade
later. It is now commonly agreed that ADHD is usually
associated with the presence of one or more major prob-
lems/disorders and that, often, these problems are at
least as important as ADHD in contributing to the
longer term outcome in the individual child.
Overall prevalence of ADHD and co-existing
disorders
ADHD is present in at least 4–7 % of all school-age chil-
dren [89]. It is associated with at least one other DSM
diagnosis in a vast majority of all cases, ranging from
about 60–100 % depending on the sample [43, 47, 62, 66,
116]. Even in a community-based sample of seven-year-
olds, 87 % of those meeting diagnostic criteria for
ADHD also met criteria for at least one more (often two
or three more) DSM-III-R diagnosis [69]. As many as
two in three of all individuals with ADHD in the general
population meet criteria for at least two additional
DSM-III-R diagnoses, meaning that young children with
ADHD are usually handicapped by several different
types of psychiatric/developmental problems.
It seems clear that having made a diagnosis of ADHD
in any individual, child or adult, the clinician would have
to – always – consider a whole range of possible co-ex-
isting disorders. These include DCD, oppositional defi-
ant disorder (ODD) and conduct disorder (CD), depres-
sion and anxiety disorder, bipolar disorder (BPD), tic
disorders (TD) including Tourette syndrome, obsessive-
compulsive disorder (OCD), and ASD. In addition, a
wide variety of learning problems are associated with
ADHD and these need to be separately addressed both
as regards assessment and interventions.
Oppositional defiant disorder (ODD)
and conduct disorder (CD)
ODD and CD probably represent the most talked about
co-existing problem conditions in ADHD [1, 25, 69, 70,
78, 120]. About 50–60 % of all children with ADHD meet
criteria for ODD. The rate is even higher in the combined
subtype of ADHD, and correspondingly significantly
lower in the mainly inattentive subtype. Prevalence ap-
pears to be equally high in preschool children as in chil-
dren in primary school, and there is little evidence of a
clear increase in rate of ODD over time in ADHD [70].
Interestingly, in one study [70] of “subclinical ADHD”,
the rate of associated ODD dropped to levels that are not
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significantly different from that of the general popula-
tion of children. This is quite unlike the pattern of asso-
ciation seen between ADHD and DCD, where co-exis-
tence of disorders extends into the subclinical variant of
ADHD. Thus, it has been argued that ODD may be either
a marker for symptom severity in ADHD or an index of
a particularly severe variant of ADHD which may differ
qualitatively from ADHD without ODD.
The extent to which ODD predicts later conduct
problems has not been as thoroughly examined in em-
pirical study as many clinicians (and researchers) ap-
pear to believe [82]. There is a commonly held view that
ADHD precedes ODD which in turn precedes CD which
in turn precedes antisocial personality disorder. It has
been documented that early childhood onset CD is usu-
ally associated with ADHD [83]. That ADHD,CD and an-
tisocial personality disorder are linked in a robust way
appears to be beyond doubt, but the role of ODD in this
chain of event still awaits confirmation from the longi-
tudinal studies of preschool onset ODD that are cur-
rently in progress.
Children with ADHD without early signs of ODD
present with anxiety and learning problems rather than
CD in adolescence [84].
A recent study suggested that from the neurophysio-
logical point of view, children with ADHD without
ODD/CD are more impaired than children with the
combination of the two types of disorder. These results
were interpreted as showing evidence for a distinct con-
dition of hyperkinetic conduct disorder as outlined in
the ICD-10 [6].
Depression and anxiety disorders
In the first longitudinal study of co-existing disorders in
ADD, 16–26 % of primary school age children in the gen-
eral population meeting criteria for ADD (regardless of
whether or not there was co-existing DCD) also met cri-
teria for a “depressive syndrome” [43, 49]. Another 12 %
had “emotional disorder” (equivalent to anxiety disor-
der) unassociated with depressive syndrome. The rate of
depressive disorder appeared to be at similar rates at 7,
10 and 13 years of age, even though different children
with ADD might be affected at different ages.
Interestingly, in the British Child Mental Health sur-
vey [35], anxiety disorder was not “comorbid” with
ADHD when adjustment for the presence of a third DSM
disorder had been made. Some authors have suggested
that the common link might be an underlying neurode-
velopmental problem/disorder, such as minor neurolog-
ical problems/DCD [e, g, 111, 127].
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Bipolar disorder
When Biederman’s group drew attention to the possibil-
ity that bipolar disorder with early childhood onset
might be mistaken for ADHD [11], many authorities
warned that he was out on a limb. It is not yet accepted
that bipolar disorders can have their onset in the first
few years of life and that one of the most likely “misdi-
agnoses” is ADHD. The research issue is still controver-
sial concerning the construct, prevalence, criteria, onset
and prognoses while it seems clearer that at least in ado-
lescence, elated mood, grandiosity, racing thoughts and
hypersexuality seem to be the most valid and leading
symptoms [13, 24, 40, 42, 54, 55, 71, 72, 104].
According to an Italian study, 24 % of 7–18-year-old
clinic attenders with bipolar disorder had co-existing
ADHD [87]. It has been suggested that ADHD may be
seen as a precursor of a child-onset subtype of bipolar
disorder, while CD might represent a prodromal or a
concomitant behavioral complication that identifies a
more malignant and refractory form of bipolar disorder.
Adults with ADHD and co-existing bipolar disorder
are more clinically impaired and more often meet full
criteria for combined subtype of ADHD than do adults
with ADHD without bipolar disorder [132]. ADHD in
children of bipolar probands might identify children at
highest risk for development of bipolar disorder [108].
Tic disorders including Tourette syndrome
Tics are common in a range of neuropsychiatric disor-
ders including ADHD. There is some support for the no-
tion that tic disorders plus ADHD reflect a separate en-
tity and not tow co-existing disorders [133, 134], while
other data suggest an additive model [93].
Core symptoms of tic disorders are motor and vocal
tics which wax and wane over time. Tourette syndrome
(TS) shows the concomitant symptoms of multiple mo-
tor tics and one or more vocal tic. Whereas in children
and adolescents ADHD has a low rate of remission over
a 4-year period, tics tend to decrease in about two thirds
of the cases during adolescence, but some individuals
previously unaffected by tic disorders develop tics dur-
ing the follow-up period. Tics appear to contribute little
in the way of predicting outcome in ADHD [81, 116].
About 85 % of patients with TS show associated neu-
ropsychiatric problems. These are often responsible for
any psychosocial impairment. Comorbid problems can
be found more frequently, when there is a family history
with tic disorders, early onset of tic disorders or high
severity of symptomatology [37, 107]. About half of the
cases with chronic tics or TS also meet criteria for
ADHD. The rate ranges from 25 % to 85 % [21, 67, 112].
There also appears to be a higher risk of co-existing
ADHD in those with Tourette syndrome who are se-
verely affected by tics [22]. Children with TS and ADHD
suffer from more externalizing and internalizing behav-
ior problems and show lower social adaptation than
children with TS only [19].
Usually, ADHD starts about 2 to 3 years before the
tics, while in a smaller proportion of cases ADHD can be
seen only after tic onset, and in another group ADHD is
never part of a tic disorder. Furthermore, children at risk
for tic disorders develop ADHD only in about 40 % of the
cases [85]. Thus, it cannot be argued that tic disorders
are nothing but “ADHD with tics” [e.g. 22]. Also, it is not
fully clear if ADHD with early onset may relatively often
signal the presence of “another” disorder that will only
become symptomatically striking months to several
years later. Nevertheless, early ADHD can be seen as a
risk factor for further associated psychiatric problems
like tic disorder.
Obsessive-compulsive disorders (OCD)
Very few studies have examined the co-existence of OCD
with ADHD. About 75 % of children with OCD show as-
sociated psychiatric disorders [119], mostly tic disor-
ders and emotional problems while ADHD usually co-
exists in 6–15 % of the cases. In clinical samples more
than 30 % of adolescents with OCD were also diagnosed
having ADHD, with an onset before OCD [5, 39, 53, 125].
A prospective longitudinal study of an epidemiological
cohort of almost 1000 children aged 1 to 10 years was
followed up in adolescence and adulthood. ADHD in
adolescence predicted OCD in adulthood and vice versa
[98]. In a study by Moll et al. [92] it was found, that chil-
dren with ADHD showed more severe obsessive-com-
pulsive traits compared to children with tic disorders.
Especially, when contamination fears, repetition, over-
conscientiousness and hoarding were taken into consid-
eration. Probably, this could be interpreted as a sign of
reduced flexibility/increased rigidity in these children.
Also, this fact might explain, why in some cases of
ADHD the treatment with stimulants leads to obsessive-
compulsive symptoms [75].
Schizophrenia and other non-affective psychotic
conditions
It is unclear whether or not schizophrenia is overrepre-
sented in ADHD. However, given that there is conside-
rable evidence [e.g. 56] that ADHD and related problems
are much overrepresented in adolescents with various
types of psychotic conditions – including schizophrenia
– it seems likely that there is a link between the two types
of disorder.
 C. Gillberg et al.
Co-existing disorders in ADHD – implications for diagnosis and intervention
Substance use disorders
The evidence is clear that there is a link between child-
hood onset hyperactivity disorders and later misuse of
various drugs including nicotine, alcohol and certain
stimulants. However,ADHD is often associated with CD,
and earlier literature has suggested that it is the conduct
problem that increases the risk of later substance abuse.
More recent studies have shown that ADHD and con-
duct problems interact in increasing the risk for sub-
stance use disorder symptoms [34] and that individuals
with the combination of ADHD and CD are uniquely at
risk for later substance use disorder.
Several studies now show that stimulant treatment of
ADHD does not increase the risk of later substance
abuse and that, if anything, such intervention conside-
rably decreases the risk of substance use disorder [10,
132].
Smoking is associated with ADHD. The presence of
ADHD increases the risk that an adolescent will be a cig-
arette smoker by at least three times over and above the
level in the general population [123]. Smoking usually
begins at an earlier age, persists for longer, and is more
difficult to give up in ADHD cohorts than in community
samples.
Alcohol abuse and cigarette smoking are the most
common types of substance use disorders in ADHD
[90]. It has been suggested that about one in five of all
adults with alcohol abuse suffers from ADHD and that
in alcoholism type II, this rate is even higher.
In adolescent alcohol use disorder cases seen at a
clinic, about one in three individuals have ADHD. Those
with ADHD tend to have more non-alcohol drug abuse
than other adolescents with alcohol abuse disorder [91].
Other psychiatric disorders
Several other psychiatric disorders, including eating dis-
orders and selective mutism, may be more common in
ADHD than in the population without this condition.
However, the empirical evidence is weak in this field,
mostly because the proper studies have not been per-
formed.
Conversely, however, there is evidence that ADHD is
more common in eating disorders [130] than would be
expected on the basis of population rates of the two
types of disorder. Hyperactivity may be a primary fea-
ture in anorexia nervosa (AN), characterizing the indi-
viduals even before they start dieting [77]. In bulimia
nervosa (BN) impulsivity seems to precede the eating
disorder quite often [94], and in some cases
methylphenidate has been successful in treating BN
with childhood onset ADHD [109, 115]. In a controlled
Swedish community-based study of AN with teenage
onset, 8 % had met DSM-IV criteria for ADHD as chil-
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dren [129], and childhood ADHD was even more com-
mon (17 %) in London patients with long-standing eat-
ing disorders [130].
There is considerable evidence [76] that selective
mutism is strongly associated with mild to moderate de-
velopmental disorders, including DCD. Given the strong
link between DCD and ADHD [68], it seems likely that
ADHD also would be overrepresented in selective
mutism.
Personality disorders
In adult age, individuals with ADHD are often diagnosed
as suffering from one or more of the so-called personal-
ity disorders [33, 114]. Even in late adolescence, there is
a very high rate of individuals with ADHD – with and
without concomitant DCD – who meet full symptomatic
diagnostic criteria for one or more personality disorders
[57]. The personality disorder can be of any type, but it
appears that those that involve major social dysfunction
(schizoid, schizotypical, paranoid, avoidant, obsessive-
compulsive, and borderline) may be particularly com-
mon.
It is unclear to what extent it is helpful or not to make
additional diagnoses of personality disorders in indi-
viduals who have been diagnosed in childhood or ado-
lescence as suffering from a neurodevelopmental/neu-
ropsychiatric disorder such as ADHD. It is doubtful
whether the personality disorder diagnosis contributes
anything in the way of further explicating the underly-
ing nature of the problems faced by the individual.
Nevertheless, it is important that adult psychiatrists
become aware that many of their patients meeting crite-
ria for one or more personality disorder diagnosis (of-
ten several) “really” suffer from ADHD.
Developmental coordination disorder (DCD)
DCD is probably the most consistently associated con-
dition encountered in children diagnosed with ADHD. It
occurs in about 50 % of those with a clinical diagnosis of
ADHD. Interestingly, the rate is equally high in those
with severe and moderate variants of the disorder, and
also in those with subclinical variants of the disorder
[68]. Conversely, about half of all children with DCD
meet criteria for ADHD. DCD is generally associated
with a high prevalence of attention deficit symptoms
and reading and writing disorders [26]. DCD symptoms
and perceptual problems are common in ADHD regard-
less of whether or not there is an associated learning dis-
ability [100, 103].
Clumsiness tends to become less clinically obvious
with time, and, in adult age, only about one in three of
those who showed ADHD with DCD still have major
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problems controlling fine and/or gross motor move-
ments.
Autism spectrum disorders
Autism is considered by many authorities in the field to
be a “developmental” rather than a “psychiatric” disor-
der (even though, to the present authors, it is increas-
ingly unclear what the difference between these two cat-
egories is). In its classical variant, autism is rare in
ADHD. In fact, the DSM-IV discourages making double
diagnoses in this field. Nevertheless, in very young chil-
dren there are sometimes major problems determining
whether one is dealing with severe combined subtype of
ADHD or autistic disorder (or possibly both).
Between 65 and 80 % of all clinic children with ADHD
have several symptoms of DSM-IV autistic disorder
[20]. The rate of a similar level of such symptoms in the
general population is under 10 % [23, 102]. Several stud-
ies have shown social deficits, peer relationship and em-
pathy problems to be common in ADHD [8, 58, 66].
In children with ADHD combined with DCD autistic
traits are very common indeed. In one study of severely
affected individuals with ADHD with DCD [43], almost
60 % met criteria for operationally defined “psychotic
behavior” which nowadays would almost definitely be
diagnosed under the rubric of autism spectrum disor-
ders.
Children with Asperger syndrome have a very high
rate of concomitant ADHD (and DCD) symptoms. A
community-based study indicated that a full 80 % of all
people meeting full criteria for Asperger syndrome ac-
cording to Gillberg [44] also met criteria for DSM-III-R
ADHD [29].
Language disorders
Early language delay was noted in ADD already in the
1980s [106]. Children with ADD and concomitant DCD
had delayed onset of language in 50 % of the cases. Sev-
eral more recent studies have replicated these findings
in ADHD [8, 66, 124]. Some studies have suggested that
girls with ADHD may be particularly at risk of language
delay and current co-existing language disorders [59,
124].
Learning disorders of various kinds
It has been well established that mean IQ is reduced by
3–7 points in large cohorts of children with ADHD. This
could be due to one or more of the following: (1) troughs
on certain attention-loading subtests of commonly used
IQ-tests (e. g. coding, digit span, and arithmetic on the
Wechsler scales), (2) overall slight shift of all IQ-tests to-
wards lower values, (3) a higher than expected rate of
subnormal intelligence and mental retardation/learning
disability among children with ADHD, or (4) an in-
creased rate of children with subnormal intelligence be-
ing mistakenly diagnosed as suffering from ADHD.
■ Troughs on specific subtests on IQ measurements
Many studies have identified a fairly typical profile of
neuropsychological test results in children with ADHD.
Thus, two or more of Coding, Digit Span,Arithmetic and
Information subtests on the Wechsler scales are very of-
ten depressed relative to other subtests. Also, various
tests of executive functions – including the Wisconsin
Card Sorting Test – usually reveal moderate to major
deficits [96]. However, there are also those with an
ADHD diagnosis who score generally low on all tests
without a particular profile [80].
■ Subnormal intelligence and ADHD
No formal studies, but vast clinical experience suggests
that children with subnormal intelligence who have no
indices of a specific subtest pattern on neuropsycholog-
ical testing,may show all the typical symptoms of ADHD
(particularly symptoms of inattentiveness, lack of per-
sistence and forgetfulness) in an overdemanding envi-
ronment.
■ Mental retardation/learning disability and ADHD
Population studies suggest that mental retardation may
be 5–10 times as common in ADHD as in children with-
out ADHD [69,101].Studies of the rate of ADHD in men-
tal retardation have been rare, but it is clear that preva-
lence is increased beyond the level encountered in the
population without learning disability. One US study
suggested that at the very least 15 % of individuals with
severe and profound levels of retardation may meet cri-
teria for ADHD even when mental age has been taken
into account [36].
■ Reading disorder, disorder of written expression,
and dysgraphia
Reading disorder is common in ADHD. About 25–40 %
of all with ADHD and 50–80 % of those with ADHD who
also have DCD have major reading and writing difficul-
ties [7, 66, 113]. The overlap of ADHD and reading dis-
orders seems to be largely accounted for by genetic over-
lap [38]. Some studies suggest that ADHD and reading
 C. Gillberg et al.
Co-existing disorders in ADHD – implications for diagnosis and intervention
disorder combined may show an interactive effect such
that attention deficits are more likely to be pervasive and
visuomotor problems more severe than would be ex-
pected on the basis of simply adding one disorder to the
other [74].
Disorder of written expression is characterized by
significant impairment in writing grammatically cor-
rect sentences and organized paragraphs. It is often as-
sociated with dysgraphia (extremes of poor handwrit-
ing). Both types of problems are common in ADHD, but
it is unclear how much overrepresented they really are as
compared with the general population [31].
■ Mathematics disorder
The overlap between ADHD and mathematics disorder
is considerable, with prevalence rates estimated from
10 % to 60 % [7, 110]. However, the estimates have been
derived from clinic samples, not community studies,
and so ascertainment bias may have led to inflated rates.
It appears that mathematics disorder is more strongly
associated with the inattentive subtype of ADHD [121].
Criminality
Many recent studies suggest strong links between child-
hood ADHD and later criminality of various kinds and
between adult criminal behavior and a childhood his-
tory of ADHD [8, 86, 105]. It appears that the symptoms
of hyperactivity-impulsivity, but not inattention, con-
tribute to the risk for criminal involvement over and
above the risk associated with early conduct problems
alone [3].
Accidents
A handful of studies on children suggest markedly in-
creased risk of accident proneness in ADHD [9, 48, 65,
79, 122].ADHD appears to confer an increased risk of all
types of accidents including early childhood ingestion
of dishwashing powder, brain concussion, fractures,
and, in late adolescence/early adult life, car crashes.
Links with underlying medical disorders
Many chromosomal and metabolic/neurologic disor-
ders can masquerade as ADHD. Some would argue that
if a child exhibits all the symptoms and meets diagnos-
tic criteria for ADHD, the diagnosis of this condition
should be made regardless of any associated medical
disorder being present or not.
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■ Chromosomal-genetic disorders
The Fragile X syndrome is very often associated with
ADHD [4, 52]. This genetic disorder very often presents
with marked autistic features and developmental delay
either before or in connection with onset of severe
ADHD symptomatology [45].
The 22q11 deletion syndrome (aka CATCH-22 syn-
drome, C for “Cardiac abnormality”, A for “Anomalous
face”, T for “Thymus hypoplasia”, C for “Cleft (submu-
cous soft) palate” and H for “Hypocalcemia”) often
presents with language delay, hypernasality and ADHD
(usually, but not always mainly inattentive subtype) in
the preschool period after cardiac problems and multi-
ple infections have been at the focus of attention during
the first few years of life [95]. In a group of 30 children
(7–13 years of age) with the syndrome, 43 % had ADHD,
mainly of the inattentive subtype. The ability to sustain
attention is critically impaired in many cases [95].
■ Neurological disorders
Several neurological disorders show a marked increase
in the rate of ADHD. Thus, for instance, epilepsy is asso-
ciated with ADHD in about one in three cases [28]. Even
though only about 6 % of children with ADHD have ev-
idence of epileptiform abnormalities on the EEG, this
rate is significantly higher than that observed in a nor-
mal group of children. Only a small fraction of those
with such EEG-abnormality develop epilepsy. One study
[106] found a much increased rate of a childhood his-
tory of febrile seizures – but otherwise no link to
epilepsy – in a community sample of children with co-
existing ADD and DCD.
Cerebral palsy is associated with ADHD in severe hy-
peractive impulsive/combined ADHD in 5–12 % of all
cases [51, 126].
Children of very low birth-weight have a very high
risk of suffering from ADHD on follow-up in school-age
[16, 131]. Those with low birth-weight and parenchymal
lesions/ventricular enlargement in the neonatal period
have extremely high rates of ADHD.
■ Non-neurological disorders
There is no consistent evidence linking ADHD to any
one type of non-neurological physical disorder either in
childhood, adolescence or adulthood. Nevertheless,
many physical ailments have been suggested to be asso-
ciated with ADHD in a stronger than chance fashion.
There have been several reports documenting a
(very) weak link between some thyroid disorders and
ADHD. Even though this association is rare in clinical
practice it is always important to consider the possibil-
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© Steinkopff Verlag 2004
ity that hyper- or hypofunction of the thyroid gland may
lead to symptoms (indeed the full-blown syndrome) of
ADHD.
Some of the most consistently reputed problems/dis-
orders reported to be associated with or suspected to be
perhaps linked to ADHD are sleep disorders, enuresis
and other bladder and bowel control problems, height
and weight problems, allergies, fibromyalgia, and high
blood pressure.
Sleep problems
Sleep problems are commonly reported in ADHD, both
in children who are on stimulant medication and those
who are not [8, 61, 88]. Some studies suggest that the as-
sociation with sleep disorders might be accounted for by
co-existing disorders and various kinds of psychotropic
and other medications used (particularly for the co-ex-
isting problems, but to some extent also for the treat-
ment of the ADHD) [88].
Sleep-disordered breathing appears to be no more
common in children with full syndromal ADHD than in
children without ADHD in the community [97]. How-
ever, snoring may be linked to mild ADHD-like symp-
toms that may mask the underlying breathing problem
and lead to delayed diagnosis and treatment of this con-
dition. Sleep-related involuntary movements appear to
be much more common in ADHD, and that these may be
specifically linked to ADHD rather than to co-existing
disorders or treatment. One study has suggested a link
between ADHD and restless legs syndrome in children
[99].
Bladder and bowel control problems
According to one study, children with ADHD may have
significantly higher rates of incontinence, constipation,
urgency, infrequent voiding, nocturnal enuresis and
dysuria than those without ADHD [27].
Height and weight problems
ADHD occurred in as many as 27 % of 215 patients re-
ceiving treatment for obesity [2]. In addition, several
studies have suggested some negative effect on long-
term height and weight after years of treatment with
central stimulants in ADHD. Nevertheless, the evidence
is equivocal and more recent studies have indicated that
reduction of final height may be minimal or non-exis-
tent [13].
Allergies
Asthma and other allergy associated disorders have long
been implicated as possible “comorbid” conditions in
ADHD [8]. Most of the published evidence runs counter
to the notion of a true association between allergies and
ADHD or vice versa.
Perthe’s disease
This hip disorder is typically encountered in children of
preschool age who, more or less suddenly, start limping.
It is listed here, not because there have been any pub-
lished empirical studies of a possible connection be-
tween ADHD and Perthe’s disease, but because some or-
thopedists have suggested to the first author that many
of their young patients with this hip problem may have
ADHD.
Fibromyalgia
Fibromyalgia is a common condition in adults, particu-
larly in women. Some adult psychiatrists with vast expe-
rience of this patient group (e. g. Zachrisson, personal
communication) believe that the rate of ADHD is much
increased over baseline population prevalence in this
condition.
Hypertension
Blood pressure is significantly increased in individuals
with ADHD who are treated with central stimulants
and/or atomoxetine. It is unclear at this stage whether or
not such treatment will have any lasting effect on blood
pressure, whether the risk of later hypertension is in-
creased, or whether – if the risk is indeed increased –
this would be due to the underlying disorder itself or to
its treatment.
Gender aspects on co-existing disorders
ADHD is much more common in males than in females
according to all clinical studies published to date. The
marked overrepresentation is less pronounced in popu-
lation studies, but it is also clearly there in all of these.
However, recent studies suggest that ADHD may of-
ten be missed in young girls and adolescents (Gillberg
et al., in progress). Other diagnoses (including depres-
sion, anxiety disorder, substance use disorder, border-
line personality disorder) are often made long before the
diagnosis of ADHD is properly considered and assessed
[73].
Clinical diagnostic implications of co-existence
of disorders in ADHD
The fact that ADHD is almost always associated with at
least one other significant disorder needs to be heeded
by all professionals working with children and adoles-
 C. Gillberg et al.
Co-existing disorders in ADHD – implications for diagnosis and intervention
cents. Given that ADHD is a very prevalent condition
that most doctors will be asked to evaluate at one or
other time in their practice the medical community
must be prepared to assess ADHD and always with a
view to also uncover and diagnose the co-existing disor-
ders.
■ The range of possible co-existing disorders
that may need to be addressed
DCD, ODD, depression and anxiety disorders, and vari-
ous types of substance used disorders need to always be
considered as likely co-existing problems in any indi-
vidual diagnosed as suffering from ADHD. In addition,
all cases need to be assessed with a view to picking up a
range of possible learning problems and autistic symp-
toms. Tic syndromes and bipolar disorder should also
always be considered.
■ Assessment tools
There are excellent screening devices for identifying
problems associated with DCD, ODD, and depression.
The motor control problems will usually manifest on a
simple test of motor functions that will take no more
than a few minutes to perform [46, 66]. ODD can be
picked up on the SNAP proforma [118], and there are
several good screening instruments for depression in
children, including that devised by Birleson [15]. Autis-
tic symptoms can be screened in 6–16-year-olds by us-
ing the ASSQ [29, 30]. The other disorders can be sus-
pected after probing into the symptoms as listed in the
DSM-IV. If learning problems exist, children with ADHD
will need psychometric testing with intelligence tests,
such as the WISC-III [128] or reading tests etc., and so
the background of the learning problems will be picked
up.
■ Differential diagnosis
Very early onset severe hyperactivity should always
alert the clinician to the presence of one or more of a
set of syndromes that may present with all or most of
the symptoms of ADHD. These are, apart from ADHD,
autism, bipolar disorder and Tourette syndrome.
Autism should be suspected when a hyperactive child
shows little or no interest in other children or if there is
a limited, rigid repertoire of behaviors, dominated by
motor stereotypies or narrow interest patterns. Bipolar
disorder should be considered whenever there is a
family history of bipolar disorder and when the hyper-
activity is linked to severe mood swings, irritability,
bouts of crying, and, albeit more rarely, elated
I/87
mood/grandiosity, racing thoughts and hypersexuality.
Tourette syndrome may present with classic ADHD
symptoms and tics may not emerge until later (some-
times many years later).
■ Gender aspects
At all ages, clinicians need to be aware that females with
ADHD may present with slightly or much less alarming
“external” symptoms of the disorder. It is more likely
that girls will present with (or first be diagnosed as hav-
ing) another disorder – such as depression, anxiety or
borderline personality disorder – before a diagnosis of
ADHD is even considered.
■ Age aspects
In school age children, the diagnosis of ADHD is usually
not difficult to establish for clinicians well acquainted
with the disorder. However, in very young children, there
is a risk of both over- and underdiagnosis.Autism, bipo-
lar disorder and Tourette syndrome may all present with
marked ADHD symptomatology leading to the “under-
lying” disorder sometimes being missed for months or
even years. Conversely, there is a considerable risk that
the diagnosis of ADHD may be missed in these other
disorders, particularly in autism and its spectrum dis-
orders in which – tradition has it – “double diagnosis”
should not be made. Also, there is a very real risk that
ADHD might be missed altogether in any adult present-
ing with academic failure, psychiatric disorder,“person-
ality disorder”, substance use disorder or criminal be-
haviors of various types.
Intervention aspects
When it comes to intervention, one has, again, to con-
sider the epidemiological perspective. ADHD is a very
common condition, and most affected individuals will
need some intervention or other. Thus, given the limita-
tions in terms of available expertise and staff, it is unre-
alistic to assume that all with ADHD must be given a
very comprehensive treatment program.
The majority of those with mild variants and even
some of those with moderate problems will have to
make do with diagnosis, information and fairly simple
psychoeducative measures [66].
For those with severe disorder, many will be in need
of a comprehensive, and in-depth intervention program,
comprising diagnosis, information, psychoeducation,
special education, medication and long-term follow-up
[89].
Given the almost universal phenomenon of “comor-
I/88 European Child & Adolescent Psychiatry, Vol. 13, Supplement 1 (2004)
© Steinkopff Verlag 2004

bidity”in ADHD, all individuals who come for treatment
of ADHD need to be fully assessed for the presence of
co-existing disorders. This holds equally true of young
children, adolescents, and adults. The clinician in charge
of the service needs to be well acquainted with all the
various possible co-existing disorders, and be prepared
to diagnose them, and, if indicated, treat them. Thus, it is
likely, not unlikely, that an individual with ADHD will
need intervention because of, for instance, clumsiness
(DCD), depression and tic disorder in addition to the
treatment prescribed for his/her ADHD. Only a very few
examples of what needs to be done in the way of inter-
vention for co-existing disorders in ADHD can be pro-
vided here.
Clumsiness may need addressing through the aid of
the child’s physical education teacher, an occupational
therapist or a physiotherapist. Fine motor clumsiness is
also positively affected by pharmacological treatment
with a central stimulant [47].
Depression, dysthymia, and anxiety in ADHD usually
do not respond to treatment with central stimulants. Oc-
casionally dysthymia and depressive features become
prominent in the early stages of stimulant treatment,
sometimes perhaps as a consequence of the child be-
coming more focussed and attentive to his/her own
needs and feelings. The realization that there are major
problems may lead to a feeling of sadness, even of loss.
This is usually a transient phase that should be treated
either by lowering the dose of the stimulant slightly or
simply by explaining the likely mechanism to the child.
When there is real co-existing depression, an antide-
pressant may need to be added to the stimulant. Alter-
natively, a non-stimulant drug, such as atomoxetine or
venlafaxine may be a better choice.
Oppositional defiant symptoms are usually amelio-
rated to some extent by central stimulant treatment, but,
in severe cases, other drugs (low dose risperidone or
olanzapine) or a parent training program (or both) may
need to be added.
Co-existing tic disorders may occasionally need, be-
sides treatment with stimulants for ADHD, additional
medication with dopaminergic blockers like sulpiride
and tiapride or the use of risperidone. Such a treatment
combination may also solve the problem of deteriorat-
ing tics with stimulants in some cases.
Autism spectrum disorders and autistic features in
ADHD will benefit from interventions that are appro-
priate for children with autism without ADHD [60].
Outcome
Not much is known about how co-existing disorders af-
fect the outcome of individuals with ADHD in the long-
term perspective. It is clear that the presence during the
middle to late school years of major oppositional prob-
lems and conduct disorder is a negative prognostic sign
in terms of later substance use disorder, antisocial devel-
opment and criminality.The presence of DCD may signal
a rather different outcome with learning problems,autis-
tic-type features, and academic failure. In the future, it
will be important to include assessment of all types of co-
existing problems in long-term follow-up natural out-
come and treatment studies in order to establish the con-
tribution of these additional problems in ADHD to the
ultimate prognosis in inattentive and hyperactive chil-
dren.
Closing remarks
ADHD is a public health problem, affecting about 5 % of
the child population, and possibly as many as 3 % of all
adults. ADHD is also a complex disorder with compli-
cated intervention implications. Virtually all of those
who seek medical or psychological help have at least one
(usually two or more) major associated disorders/types
of problems. These problems need to be assessed, diag-
nosed and considered for various types of intervention
strategies in their own right.As children grow up, the co-
existing disorders are often those that attract the most
attention. It is currently the case that the “underlying”
ADHD problems remain unaddressed in adults with
various types of complicating psychiatric and personal-
ity disorders.
A consequence of the demonstration of this very high
rate of co-existing problems in ADHD, is that it would
not be appropriate to develop ADHD-services where
clinicians would only have expertise in ADHD as such.
Anyone working with children, adolescents or adults
with ADHD would need to have training in general neu-
ropsychiatry.

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