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Review
. 2016 Oct;138(4):e20160430.
doi: 10.1542/peds.2016-0430. Epub 2016 Sep 21.

Patterns of Comorbidity Among Girls With ADHD: A Meta-analysis

Irene Tung  1 , James J Li  2 , Jocelyn I Meza  3 , Kristen L Jezior  1 , Jessica S V Kianmahd  1 , Patrick G Hentschel  1 , Paul M O'Neil  1 , Steve S Lee  4
Affiliations
Review

Patterns of Comorbidity Among Girls With ADHD: A Meta-analysis

Irene Tung et al. Pediatrics. 2016 Oct.

Abstract

Context: Although children with attention-deficit/hyperactivity disorder (ADHD) are at elevated risk for comorbid psychopathology, the clinical correlates of ADHD in girls are far less understood relative to boys, despite ADHD being one of the most common childhood disorders in girls.

Objective: To meta-analytically summarize rates of comorbid internalizing (anxiety, depression) and externalizing (oppositional defiant disorder [ODD], conduct disorder [CD]) psychopathology among girls with and without ADHD.

Data sources: Literature searches (PubMed, Google Scholar) identified published studies examining comorbid psychopathology in girls with and without ADHD.

Study selection: Eighteen studies (1997 participants) met inclusion criteria and had sufficient data for the meta-analysis.

Data extraction: Odds ratios for each comorbid disorder were calculated from available data. Demographic (eg, age, race/ethnicity) and study characteristics (eg, referral source, diagnostic method) were also coded.

Results: Compared with girls without ADHD, girls with ADHD were significantly more likely to meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for each comorbid disorder assessed. Relative odds were higher for externalizing (ODD: 5.6×; CD: 9.4×) relative to internalizing disorders (anxiety: 3.2×; depression: 4.2×). Meta-regression revealed larger effect sizes of ADHD on anxiety for studies using multiple diagnostic methods, featuring younger children, and including clinic-referred (versus community-referred) girls; the effect of ADHD on ODD varied based on diagnostic informant.

Limitations: Findings were derived from cross-sectional studies, precluding causal inferences.

Conclusions: Girls with ADHD frequently exhibit comorbid externalizing and internalizing disorders. We discuss future research priorities and consider intervention implications for ADHD and comorbid psychopathology in girls.

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Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: The authors have indicated that they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated that they have no financial relationships relevant to this article to disclose.

Figures

FIGURE 1. Flowchart of study inclusion.
FIGURE 1
Flowchart of study inclusion.
FIGURE 2. Forest plot graphing ORs for ODD among girls with versus without ADHD. Each study is represented by 1 horizontal line and box, with location of the box on the x-axis corresponding to the point estimate for each study, and the size of the box indicating the weight (inverse of variance) of the study. The diamond and dotted vertical line depict the overall effect estimate for all 18 studies, with the width of the diamond representing the CI.
FIGURE 2
Forest plot graphing ORs for ODD among girls with versus without ADHD. Each study is represented by 1 horizontal line and box, with location of the box on the x-axis corresponding to the point estimate for each study, and the size of the box indicating the weight (inverse of variance) of the study. The diamond and dotted vertical line depict the overall effect estimate for all 18 studies, with the width of the diamond representing the CI.
FIGURE 3. Forest plot graphing ORs for CD among girls with versus without ADHD. Each study is represented by 1 horizontal line and box, with location of the box on the x-axis corresponding to the point estimate for each study, and the size of the box indicating the weight (inverse of variance) of the study. The diamond and dotted vertical line depict the overall effect estimate for all 15 studies, with the width of the diamond representing the CI. ES, effect size.
FIGURE 3
Forest plot graphing ORs for CD among girls with versus without ADHD. Each study is represented by 1 horizontal line and box, with location of the box on the x-axis corresponding to the point estimate for each study, and the size of the box indicating the weight (inverse of variance) of the study. The diamond and dotted vertical line depict the overall effect estimate for all 15 studies, with the width of the diamond representing the CI. ES, effect size.
FIGURE 4. Forest plot graphing ORs for anxiety among girls with versus without ADHD. Each study is represented by 1 horizontal line and box, with location of the box on the x-axis corresponding to the point estimate for each study, and the size of the box indicating the weight (inverse of variance) of the study. The diamond and dotted vertical line depict the overall effect estimate for all 11 studies, with the width of the diamond representing the CI.
FIGURE 4
Forest plot graphing ORs for anxiety among girls with versus without ADHD. Each study is represented by 1 horizontal line and box, with location of the box on the x-axis corresponding to the point estimate for each study, and the size of the box indicating the weight (inverse of variance) of the study. The diamond and dotted vertical line depict the overall effect estimate for all 11 studies, with the width of the diamond representing the CI.
FIGURE 5. Forest plot graphing ORs for depression among girls with versus without ADHD. Each study is represented by 1 horizontal line and box, with location of the box on the x-axis corresponding to the point estimate for each study, and the size of the box indicating the weight (inverse of variance) of the study. The diamond and dotted vertical line depict the overall effect estimate for all 12 studies, with the width of the diamond representing the CI.
FIGURE 5
Forest plot graphing ORs for depression among girls with versus without ADHD. Each study is represented by 1 horizontal line and box, with location of the box on the x-axis corresponding to the point estimate for each study, and the size of the box indicating the weight (inverse of variance) of the study. The diamond and dotted vertical line depict the overall effect estimate for all 12 studies, with the width of the diamond representing the CI.
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