A recent Hungarian study published in BMC Psychiatry showed that adolescents with attention-deficit hyperactivity disorder (ADHD) have an increased risk for nonsuicidal self-injury (NSSI). The link is especially significant in girls.
Previous research had shown that more than two-thirds of patients with ADHD have at least one psychiatric comorbidity. The disorder is also related to suicidality in all age groups and both sexes, and comorbid conditions may mediate this association.
Nonsuicidal self-injury was recently identified as an individual diagnosis in the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5). It is defined as deliberate, nonsuicidal purpose of self-injury that is not a culturally sanctioned behavior. Prevalence in the adolescent population is believed to be between 13% and 45%, and between 40% and 80% in a clinical sample of adolescents.
For this study, the investigators enrolled inpatients at the Vadaskert Child and Adolescent Psychiatric Hospital and Outpatient Clinic in Budapest, Hungary. Participants were between the ages of 13 and 18. Parents provided written informed consent, and no economic or other type of compensation was provided.
The team used the Hungarian version of the modified Mini International Neuropsychiatric Interview Kid (MINI KID) 2.0, a structured diagnostic interview that assesses major psychiatric disorders in children and adolescents, such as affective disorders, anxiety disorders, oppositional defiant disorder (ODD), and others. All interviewers participated in a training course before the study and were regularly supervised.
Self-injuries were evaluated by the Deliberate Self-Harm Inventory (DSHI), a self-rated questionnaire that assesses whether people engage in direct self-injury behavior; self-inflicted damage to the skin by self-cutting, self-burning, self-hitting, or self-biting; and skin damage by other methods.
In all, 202 patients participated in the study; 99 were boys and 103 were girls. Mean age was 14.87 years. Fifty-two patients (25%), including 23 boys and 29 girls, fulfilled the diagnosis of ADHD according to the MINI Kid.
Of the patients with ADHD, 35 (67.3%, 10 boys and 25 girls) had NSSI. The most common comorbid mental disorders of adolescents with both ADHD and NSSI included suicidality (94%), ODD (66%), generalized anxiety disorder (63%), and psychotic disorder (60%).
The association among ADHD, NSSI, and comorbid mental disorders was analyzed using the Spearman correlation. Results showed no statistically significant direct pathway from ADHD to NSSI in patients of either sex. Symptoms of ADHD and prevalence of NSSI were mediated by the comorbidities. Mediating factors included affective disorders, psychotic disorder, and suicidal behavior in both sexes, and alcohol abuse and dependence for girls only.
The authors noted that evidence has shown that NSSI is commonly used to avoid, regulate, reduce, or escape from negative emotions. In addition, ADHD symptoms have multiple everyday negative effects with several conflict points. These can combine to produce low self-esteem, frustration, and a depressed mood, which may explain the mediator role of the symptoms of depression between the symptoms of ADHD and NSSI.
“The high prevalence of NSSI, especially in the case of girls, and its overlap with suicidality among adolescents with the symptoms of ADHD, calls to the attention of clinicians the importance of screening routinely for the risk factors of NSSI and suicidality in this population, with a special focus on girls,” the authors concluded. “While the symptoms of comorbid conditions of ADHD, such as affective disorders, suicidality, alcohol abuse/dependence, and psychotic disorders, fully mediate the relation between the symptoms of ADHD and NSSI, the early recognition and treatment of the symptoms of ADHD and these conditions can be important in the prevention of NSSI.”
To read more about this study, click here.