Sex Differences in Comorbidity Patterns of Attention-Deficit/Hyperactivity Disorder

J Am Acad Child Adolesc Psychiatry. 2019 Apr;58(4):412-422.e3. doi: 10.1016/j.jaac.2018.07.910. Epub 2019 Jan 8.


Objective: To investigate sex differences in associations between attention-deficit/hyperactivity disorder (ADHD) and a spectrum of comorbid disorders.

Method: The study population included all children born in Denmark from 1981 through 2013 (N = 1,665,729). Data were merged from Danish registers and information was obtained on birth characteristics, socioeconomic status, familial psychiatric history, and diagnoses of ADHD (n = 32,308) and comorbid disorders. To estimate absolute and relative risks of comorbid disorders, incidence rates and adjusted hazard ratios (HRs) with 95% CIs were calculated for female and male individuals. In addition, interactions between ADHD and sex in association with comorbid disorders were estimated as HR ratios (HRRs) in female and male individuals (95% CIs).

Results: Individuals diagnosed with ADHD had significantly increased absolute and relative risks of all 12 comorbid psychiatric disorders investigated. ADHD-sex interactions were found for some comorbid disorders. Compared with male individuals, ADHD in female individuals showed a stronger association with autism spectrum disorder (HRR 1.86, 95% CI 1.62-2.14), oppositional defiant/conduct disorder (HRR 1.97, 95% CI 1.68-2.30), intellectual disability (HRR 1.79, 95% CI 1.54-2.09), personality disorders (HRR 1.23, 95% CI 1.06-1.43), schizophrenia (HRR 1.21, 95% CI 1.02-1.43), substance use disorders (HRR 1.21, 95% CI 1.07-1.38), and suicidal behavior (1.28, 95% CI 1.12-1.47). The remaining disorders showed no significant sex differences in association with ADHD.

Conclusion: This study indicates that the association between ADHD and several comorbid disorders is stronger in female than in male individuals. These important findings add to the literature on sex differences in ADHD and suggest that female individuals diagnosed with ADHD are a more vulnerable group of patients.

Keywords: ADHD; comorbid disorders; sex differences.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Attention Deficit Disorder with Hyperactivity / epidemiology*
  • Attention Deficit Disorder with Hyperactivity / psychology
  • Autism Spectrum Disorder / epidemiology
  • Child
  • Child, Preschool
  • Comorbidity*
  • Denmark / epidemiology
  • Female
  • Humans
  • Intellectual Disability / epidemiology
  • Male
  • Personality Disorders / epidemiology
  • Proportional Hazards Models
  • Risk Factors
  • Sex Factors*
  • Substance-Related Disorders / epidemiology