The majority of kids seen in a practice like mine exhibit symptoms of more than one mental health disorder. This phenomena, in which kids who meet the diagnostic criteria for one condition are observed to have a higher than expected prevalence of another condition is referred to by psychiatrists as comorbidity.
The concept of comorbidity is important to understand because it helps to explain why kids who carry the same diagnosis may react very differently to environments or experiences at church, why we very much try to avoid the use of diagnostic labels when working with churches and why it is so important for ministry leaders and parents to view each child as a unique individual.
This concept, along with the propensity of mental health professionals to assign kids with a new diagnosis every time they meet enough of the symptom criteria in the DSM-5 (the diagnostic manual for mental health conditions used across professions) is viewed with a not insignificant degree of contempt by other fields in medicine. When I was an intern at Cleveland Clinic, my attending docs constantly drilled into us the importance of trying to identify one underlying cause to explain as many of the signs and symptoms we observed in a given patient as possible. The need to use multiple diagnoses may be a sign of the inadequacy of our current system of diagnosing mental health disorders, and an inadequate understanding of the root causes of many of the conditions we see.
Allow me to present an example of how this notion of comorbidity complicates the way in which kids with one common condition present. Below is a slide examining rates of comorbidity of several mental health disorders among school-age kids with ADHD:
Looking at a slide like the one above leads us to ask why we might see these relationships between different conditions…here are some thoughts:
It’s possible that two conditions may share the same underlying cause. This is an interesting hypothesis that folks examining the relationship between ADHD and specific learning disabilities are exploring. By some estimates, learning disabilities may be five times more common among kids with ADHD compared to kids in the general population.
One disorder may represent a subset of symptoms associated with a given condition. For example, there’s been a fair amount of debate about the validity of the diagnosis of Oppositional Defiant Disorder (ODD), with some arguing that the symptoms described represent a subset of symptoms seen in association with ADHD.
The experience of having one condition may predispose the child to developing a second condition. For example, do the academic difficulties, disruption in peer and family relationships and difficulties with emotional/behavioral self-regulation seen in many kids with ADHD put them at greater risk of depression as teenagers?
Could there be a genetic linkage between two conditions? For example, a very high percentage of kids with juvenile-onset bipolar disorder (90%) have ADHD, but a relatively low percentage of adults with bipolar disorder (10-15%) have ADHD. Are the genes associated with juvenile-onset bipolar disorder closely linked to genes associated with ADHD?
In my next post on comorbidity, we’ll spend some time looking at patterns of comorbidity associated with other mental health conditions in kids, and how such patterns complicate the types of accommodations and supports kids are likely to require and challenge our ability to utilize the available treatments for their conditions.
Most recently revised 2/14/14
Confused about all the changes in diagnostic terminology for kids with mental heath disorders? Key Ministry has a resource page summarizing our recent blog series examining the impact of the DSM-5 on kids. Click this link for summary articles describing the changes in diagnostic criteria for conditions common among children and teens, along with links to other helpful resources!
I have a child labeled with both juvenile-onset bipolar disorder and ADHD. The worst thing about it is the fact that most of the meds for one aggravate the other.
Jon…what you describe is very typical of the challenges our families face. Our most challenging kids have bipolar disorder, ADHD AND an anxiety disorder.
I am sure that is in his mix somewhere. I think some of the ADHD symptoms in another child of mine comes from her anxiety and the lack of rest that results. Without proper rest she is on edge, fidgety and unable to concentrate.
Thank you. This info is so helpful.
Not sure if you remember me, but I was the director for early childhood Sunday School for many years @ BPC under Libby P. Currently, John & I are directors of WEC, Int. (USA) near Philly. I have been asked to write the chapter on family for Dr. Phyllis Kilbourn for a new parent handbook she is editing on children with disabilities. She is a well respected, worldwide expert of children in crisis and is the founder of Rainbows of Hope, WEC’s children ministry. All that to say – i.e to ask: May I have your permission to include Key Ministry as a resource, as well as mentioning your definition of comorbidity in my chapter? I will make sure to mention your name. All writers are volunteers and any profit from sales are plowed back into the ministry.
Thank you so much for your consideration. In Him,
Marie, of course I remember you. I trust that years in the mission field prepared you for life in Philly. Has WEC identified families of kids with disabilities as a target people group?
We’d be honored to do anything we can to help with the book project, or anything else WEC is doing to help serve families of kids with disabilities.
Having more than one disorder is annoying. I have OCD as well as high functioning autism and mild asphergers with a slight possibility of a few other disorders (there are a few more disorders that I am suspected of having but since it doesnt cause many problems we see no reason to visit a doctor about our suspicions).
My disorders rarely cause any problems anymore though since I more or less have it under control so I dont get any help or special treatment for it. I dont need it.
When I was younger and far less in control of it (as in, not at all) I did get a little bit of special treatment but nothing much (my teachers didnt understand me so I got no help from them).
I did have to go to a support group for a while to years ago but I hated it because it was telling me things I already knew and was no help. Despite my disorders I had no reason to be there because I more or less look after myself.
I got my disorders under control by myself, Im pretty sure I dont need any help playing normal after I’ve been doing it (and perfecting my preformance) for so long.
It actually quite annoys me when people suggest I need help just because my brain works in a wako way that apparently means there is something off about it. I understand that there are people with my disorders who do need the help but could people at least make an observation before chucking help at someone where it is neither wanted nor needed? How am I going to get better if I am treated differently all the time? Admittedly sometimes I do need to be treated with some understanding and consideration but that is usually only during my very rare melt-downs. Even then all I need is for the teacher or partner to understand why I seem to be struggling with a simple task I found easy just 10 seconds ago and give me a minute or two to recover rather than over-whelm me.
Thanks for your comments, and thanks for checking out the blog!
As a person with Asperger’s and other conditions, have your conditions ever represented a significant barrier to you in being actively involved in a local church?