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Objective: Attention deficit hyperactivity disorder (ADHD) is one of the most frequent psychiatric disorders of childhood. ADHD, which is a multifactorial and clinically heterogeneous disease, leads to socioeconomic burden and undesirable academic and occupational results. Other psychiatric disorders and mood problems are likely to accompany a substantial proportion of children admitted to a clinic with a diagnosis of ADHD, and this enhances the severity of the clinical picture. It is a current debate whether ADHD and non-cyclical severe irritability is a variant of a development bipolar disorder or not. However, epidemiological and phenomenological data are needed about clinical risks, prognosis markers, protective factors and treatment options. In this study, we aimed to investigate the differences between ADHD with and without mood symptoms in terms of functionality and treatment outcome.
Methods: This study is a follow-up study with a naturalistic design. Patients who were diagnosed ADHD and were started methylphenidate treatment (n=44, mean age: 10.8) were included in the study. The irritable/dysphoric group (group with mood dysregulation) is defined as children who got 8 points and more from “oppositional defiant” portion of DSM-IV-Based Screening and Rating Scale for Child and Adolescent Behavior Disorders (CABD-S) and got points between 12 -18 in Child Depression Inventory (CDI). Functionality is measured by three Likert-type items (1-5 for each) including academic, social and behavioral functionality. Clinical Global Impression (CGI) were used to determine the clinical severity of ADHD. Follow-up measurements included the CGI-Severity, Functionality in the 6-12 weeks of treatment.
Results: ADHD + irritable/dysphoric group consisted of 11 children (9 boys, 2 girls, mean age: 10.9) and 33 children (18 boys, 15 girls, mean age: 10.8) in ADHD group. Functionality scores were significantly lower in the ADHD + irritable/dysphoric group compared to the control group (social: 2.5 vs. 3.0; behavioral: 2.7 vs. 3.3; academic 2.1 vs. 2.6) in the first clinical application (p<0,05). However, CGI-S scores were not significantly different (irritable/dysphoric group: 5.7 vs. control: 5.6). Methylphenidate was used at a dose of 24.7 mg/day on average. In the follow-up CGI-S scores were found to be significantly different (irritable/dysphoric group: 4.4 vs. control: 3.9) (p<0.05).
Conclusion: Comorbidity is a major problem in the clinical practice with ADHD patients. Especially irritability, defiance and depressive symptoms even without significant mood disorder diagnosis may interfere with treatment efficacy and have another burden for functionality of the patient. In this clinical sample with children, who were diagnosed with ADHD, we demonstrated that the irritability/dysphoria symptoms might decrease the level of social, behavioral and academic functionality and the response to methylphenidate treatment. More comprehensive assessments in terms of mood dysregulation in ADHD patients are needed in further studies.