Attention-deficit hyperactivity disorder and suicidality in a treatment naïve sample of children and adolescents

Abstract

Background

The aim of the present study was to investigate the possible association between attention-deficit/hyperactivity disorder (ADHD) and suicidality.

Methods

Using a structured interview (Mini International Neuropsychiatric Interview Kid), the authors examined 418 treatment naïve children/adolescents (aged: 3–18 years). Suicidality was defined by the M.I.N.I. Kid as having any current suicidal ideations and/or suicide attempts.

Results

Two hundred and eleven children/adolescents fulfilled the DSM-IV diagnosis of ADHD and a further 105 showed symptoms of ADHD in subthreshold level. Multiple mediation analyses resulted in a moderated meditational model in which the relationship between symptoms of ADHD and current suicidality was fully mediated by the symptoms of comorbid conditions, but this was moderated by age. In children under 12 years, significant mediators were the symptoms of specific anxiety disorders, while in the adolescent group symptoms of major depressive episode and dysthymia and symptoms of substance abuse/dependence approved as significant mediators.

Limitations

As the study was cross-sectional, it did not reveal any causal relationship among the investigated factors. Furthermore, as the study population included a treatment naïve clinical sample, we can assume that adolescents, who and/or whose family seek for help at the first time in this age belonged to the less sever end of the spectrum.

Conclusions

ADHD symptoms are associated with an increased risk of suicidality in treatment naïve children/adolescents. The mechanisms of this relationship can be understood only when developmental factors are considered. Our findings suggest that clinicians should screen suicidality and comorbid symptoms routinely in patients with ADHD.

Introduction

Suicide is the second leading cause of death among people aged 15–24 years in Europe and the third in the US (World Health Organization, 2012). Several studies showed that similar to adults most youth who commit, attempt or think about suicide have at least one concurrent psychiatric disorder (Brent et al., 1988, Gould et al., 2003, Fergusson and Lynskey, 1995, Marttunen et al., 1991, Shaffer et al., 1996). Among psychiatric disorders mood disorders, substance use disorder and conduct disorder are the well-known leading suicide risk factors in this age group (Beautrais, 2003, Brent et al., 1988, Brent, 1995, Cavanagh et al., 2003, Gould et al., 2003, Lowe and Gibson, 2005, Lowenstein, 2005).

Recently there is a growing interest in a possible association between attention-deficit/hyperactivity disorder (ADHD) and suicide (Biederman et al., 2008, Cho et al., 2008, Chronis-Tuscano et al., 2010, Galéra et al., 2008, Goodman et al., 2008, Lam, 2005, Manor et al., 2010).

Lam (2005) reported a four-fold higher likelihood of having the diagnosis of ADHD for children and adolescents hospitalized for suicide attempts and self-harm. In their pilot study Manor et al. (2010) found that 65% of the adolescents who had attempted suicide met the criteria of ADHD, but only 22% of them had been diagnosed with ADHD prior to suicide attempt.

The results on the possible association between ADHD and suicidality are controversial: the main question is whether there is a direct association between ADHD and suicidality or ADHD increases the risk of suicide by increasing the prevalence of comorbid conditions.

Reviewing the age aspect of the studies on the possible association between ADHD and suicidality, the vast majority of them focused on adolescents or adults (Cho et al., 2008, Manor et al., 2010) and there are only a very few studies which investigated children under 12 (Goodman et al., 2008). Additionally to our knowledge it has not been done any research on the suicidality of treatment naïve children and adolescents with the symptoms of ADHD.

Despite of this lack in the literature it is well known that the prevalence and pattern of psychiatric comorbidity of children and adolescents with ADHD differ (Huh et al., 2011, Taurines et al., 2010).

During the last decades several researchers highlighted that both categorical and dimensional approaches to diagnosis are important for clinical work and research as well (Helmchen and Linden, 2000, Lecrubier, 2008, Möller, 2008, Okasha, 2009). Previous studies suggested that subthreshold disorders, which can be defined as syndromes, which do not fulfill the required criteria of threshold definition (according to the classification systems) have a negative impact on education/work impairment, quality of life, comorbidity (both with other subthreshold and threshold disorders) and suicide as well (Balázs et al., 2000, Balázs et al., 2013, Bertha and Balázs, 2013, Lecrubier and Ustun, 1998, Olfson et al., 1996, Oral et al., 2012, Wittchen et al., 1998).

The aim of the present study was to describe the prevalence of suicidality in a treatment naïve clinical sample of children and adolescent with the symptoms ADHD and to examine weather there is a direct association between ADHD symptoms (fulfilling or not the diagnostic threshold) and suicidality in the different age groups and how the symptoms of comorbid psychiatric conditions influence it.