Problems run in Families including ADHD

Ground yourself in facts in your thinking about ADHD.
If you are overwhelmed with information on ADHD online this post will help you. There seems to be an overwhelming number of problems associated with ADHD. Is my child at greater risk for all that?

A deeper look will ease some of those fears and clarify that if there tends to be depression and/or aggression in your family then the risk for your child is related to this family trend.

Basic ADHD Statistics:

• Core symptoms: Inattention & hyperactivity.
• General prevalence rates: 5% of children mostly boys.

Let’s go through the litany: those with ADHD have more risk for drug abuse, more car accidents, more injuries, more job loss and career change, less stable relationships, etc. etc. Is this all true? Does it happen to all people with ADHD? What is the long term story or likely story of someone with ADHD? What are typical trajectories of their lives?

Family History and Co-Morbidities the Great Mediating Variables

When considering ADHD statistics the complicating factor is what we psychologists call co-morbidity.
Co-morbidity is when another problem co-occurs with ADHD. So what else is going on with your child other than ADHD?

Co-morbidity is the critical factor when attempting to understand what ADHD in children means for adult ADD. In other words, what will be the life trajectory of a person with ADHD?

A few years ago I did a thorough review of research and I concluded with an important insight:
When ADHD occurs alone then the primary problem you get is significantly lower academic achievement than you would expect for that person’s IQ level.

On a research level or a statistical level most of the other problems fade out when you remove those people who have co-morbid problems along with ADHD compared with those who have only ADHD.
This does not mean on an individual level that they never co-occur. It just means that they are not close to as likely as when you have a co-morbid problem.

The research trends continue to bear this out. A useful study by Joseph Biederman MD and Stephen Faraone PhD can be read at this link: http://adjix.com/fe5q. They studied 150 boys diagnosed with ADHD and compared them with controls (120 boys without ADHD).  What is useful about this study (Harvard Mahoney Neuroscience Institute Letter: On the Brain, Winter, 1996 Vol. 5, number 1) is that it breaks down how prevalent some of those co-morbidities are within the population of boys diagnosed with ADHD. Take a look at their graph and try to figure it out http://adjix.com/fe5q. Here are a few highlights:

ADHD Co-Morbidities:

1. 49% had ADHD alone.
2. Anxiety, Depression and Conduct disorder are common problems that are co-morbid with ADHD
3. Co-morbid disorders predicted later disorders consistent with that original co-morbidity.

Their study involved a follow up after 4 years. What they found was that if a child had anxiety then 4 years later he was likely to still have anxiety and possibly more anxiety. If he had conduct disorder he was more likely to have antisocial personality disorder (a progression beyond conduct disorder with similar, but worse problems in adulthood). If he had depression he was more likely to have mania when he was 4 years older.

So, the concept is that having ADHD alone leads to risk for academic underachievement but does not necessarily predispose a child to a life of anxiety, depression and conduct disorder. However, if he had one or more of these issues originally then they are more likely to continue and worsen.  Or if these problems were in the family already then there is a risk of them for your child.

Biederman and Faraone had some other interesting conclusions as well. I will quote them directly here: “The MGH study was the first double-blind study to clearly show not only that ADHD is familial but also that the way the illness clusters in families is most consistent with the effects of a single gene of modest effect. We were able to dismiss other explanations such as socio-cultural factors.” (Biederman and Faraone, 1996) http://adjix.com/fe5q
This quote is powerful. As has been often concluded that ADHD is primarily hereditary this study is more conclusively stating this.  ADHD comes in families.

Additionally, this study found the following:
“…ADHD and major depression are variable expressions of shared underlying risk factors and that ADHD with conduct disorder might be a distinct familial subtype of the disorder. However, anxiety and learning disorders were not tied to ADHD familially; instead, when those disorders co-occur with ADHD in families, they appear to be transmitted independently.” (Biederman and Faraone, 1996) http://adjix.com/fe5q

Let me further clarify this point.  Conduct disorder involves things like bullying others, initiating fights, using a weapon against others, physical cruelty, stealing, destroying property, stealing, etc. etc.  In other words these major infractions of rules and law are in the diagnostic category of conduct disorder.  These researchers found that these problems were a “distinct family subtype”.  In other words this lawless behavior tends to run in families that also have ADHD, but then there is a larger group in which ADHD does not include lawless behavior.  In other words these researchers found that these problems tend to run in different families.  This is a critical insight because many of the studies which include more severe problems of people with ADHD include people with problems that are associated with conduct disorder.

These findings are also very significant in that they suggest different things about intervention and prevention. In families in which depression is common with ADHD children in those families are more at risk for that combination, but conduct disorder with ADHD is a subtype. This suggests that just because a child has ADHD does not mean he is at greater risk for breaking the law and violating the rights of others, but if he has a family that tends to do so he is at more risk for that.

In contrast anxiety and learning problems were found to be transmitted independently. So, anxiety might develop out of stress related to academic struggle, social interaction, etc. Learning problems may stem from brain problems etc.

What does this mean for intervention and prevention?
1. Diagnosis of ADHD or ADD earlier and intervening earlier reduces lagging in academic achievement.
2. Co-morbidity determines whether only ADHD or another disorder(s) needs to be addressed.
3. As anyone in mental health who works with this population will tell you, families with ADHD and conduct disorder are very difficult to treat. (Keep in mind that conduct disorder symptoms include bullying other people, cruelty to others (people and/or animals, fighting, stealing, destroying property, deceit and theft.) As you would expect when this runs in a family it is hard to treat.  Intervening with these families is critical.
4. Families will tend to have patterns of depression to accompany ADHD when a child tends to have it.
So, if the family has those signs and the child doesn’t have it yet, you might prevent it with intervention.
5. Anxiety and learning problems may or may not be in the family history when they occur in a child.
6. Each subgroup is fairly distinct although there is some overlap. In other words a child with conduct disorder and ADHD will be quite distinct from a child with ADHD alone or with ADHD and anxiety.

So, when considering where your child’s life trajectory might go consider:  how he functions today, how his family functions and to what extent ADHD symptoms affect him.
Dr. Charles Shinaver

Located in Carmel, Indiana near Indianapolis, Noblesville, Fishers, Zionsville, and Westfield.

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