Evaluation of the Relationship between ADHD and Comorbid Psychiatric Conditions: A Comprehensive Study on a Large Cohort
Adeel Sarwar*
Roketsan University, Ankara, Turkey.
DOI: 10.4236/oalib.1111111   PDF    HTML   XML   35 Downloads   282 Views  


This study analyzes the intricate psychiatric landscape accompanying attention-deficit/hyperactivity disorder (ADHD), focusing on the prevalence and nature of comorbidities among diverse gender categories, including transgender and non-binary individuals. We examined data from 1528 participants using standardized diagnostic tools through the ADHDtest.ai website under the leadership of MD Adeel Sarwar. Our findings reveal a noticeable prevalence of anxiety disorders, especially in the non-binary (63.2%) and transgender (37.5%) populations, indicating an urgent need for healthcare services tailored to their needs. Additionally, among females with an ADHD diagnosis, 44.97% reported no pre-existing conditions, suggesting a distinctive presentation of ADHD in this demographic. Our approach deviates from traditional views, such as those presented in the 2016 study by Caye et al., which posited that adult ADHD must derive from childhood. The prior research, which followed 5249 Brazilian youths into adulthood, relied on DSM-5 criteria to identify ADHD’s continuity from childhood. By contrast, our study, with subjects primarily from the USA, UK, and Canada, emphasizes a nuanced gender distribution and highlights the importance of considering ADHD as possibly representing a divergent developmental path rather than solely an extension from childhood. This research stresses the necessity of gender-specific considerations in ADHD diagnosis and treatment, mirroring the National Institute of Mental Health’s recommendation for a multifaceted evaluative method to improve clinical outcomes. The data, anonymized to protect privacy, illuminates the intersection between ADHD and various psychiatric disorders, including gender-specific variations in clinical presentation and comorbidity profiles. By centering on severe ADHD manifestations in females and incorporating the experiences of transgender and non-binary individuals—groups often underrepresented in psychiatric epidemiology—the study broadens our understanding and suggests individualized therapeutic strategies that encompass all gender identities and interconnected psychiatric conditions.

Share and Cite:

Sarwar, A. (2024) Evaluation of the Relationship between ADHD and Comorbid Psychiatric Conditions: A Comprehensive Study on a Large Cohort. Open Access Library Journal, 11, 1-10. doi: 10.4236/oalib.1111111.

The study analyzed data from the ADHDtest.ai website, which comprised a cohort of 1528 individuals diagnosed with Severe ADHD across various gender identities. The datasets generated and/or analyzed during the current study are available in the ADHDtest.ai repository, accessible at https://adhdtest.ai/research-data.csv. In the event of the file being unavailable from the specified source, the data can be made available from the corresponding author upon reasonable request.

In the process of data collection for this study, ADHDtest.ai has adhered strictly to ethical standards to ensure the integrity of our research and the confidentiality and rights of all participants:

Compliance with Guidelines and Regulations: All methods involved in the study were carried out in accordance with relevant guidelines and regulations. The research design, data collection, and analysis procedures were developed to meet the highest standards of ethical research conduct.

Institutional Approval: All experimental protocols were thoroughly reviewed and approved by the R&D department from Roketsan University.

Informed Consent: Informed consent was obtained from all subjects involved in the study. Consent was given through an affirmative action by starting the ADHD online assessment, which included a clear affirmation that some of their anonymized data may be used for research purposes. This process was designed to ensure that participants were making an informed decision to contribute to the study.

Confidentiality of Data: The identity and personal information of all participants remain strictly confidential. In the transition from data collection to analysis, all datasets were anonymized to prevent any possibility of tracing data back to individual participants. This measure was taken to uphold the privacy of participants while allowing for the valuable insights from their data to contribute to the broader research community’s understanding of ADHD.

2. Methods

The study cohort comprised 1528 participants, recruited through the ADHDtest.ai website. The participants were diverse in gender, including 756 females (49.5%), 378 males (24.7%), 36 non-binary (2.4%), 32 transgender (2.1%), and 326 with an unknown or undisclosed gender (21.3%). The distribution is as specified in Table 1.

The diagnosis of ADHD was ascertained using a proprietary algorithm from the ADHDtest.ai website, which utilizes standardized diagnostic tools and criteria consistent with the DSM-5 guidelines. Upon identification of ADHD, participants disclosed any pre-existing conditions and underwent further evaluation to confirm any co-occurring psychiatric conditions.

This two-tiered diagnostic approach allowed for a thorough investigation into the prevalence and nature of psychiatric comorbidities within the ADHD population, with a particular focus on the impact of gender diversity on these comorbid conditions.

3. Comprehensive Results across All Cohorts

Out of the 1528 participants evaluated, a significant majority, 1258 individuals, were diagnosed with various degrees of ADHD, ranging from Mild to Severe, representing 82.3% of the total cohort. The investigation into comorbid psychiatric conditions among those diagnosed with ADHD revealed the following prevalence rates:

The analysis of the cohort, comprising 1528 participants, see Table 2, reveals a substantial prevalence of psychiatric comorbidities among individuals diagnosed with ADHD. Notably, anxiety disorders emerge as the most common comorbidity, affecting 40.4% of those diagnosed with ADHD. This finding is consistent with extant literature that posits a significant neurobiological overlap between ADHD and anxiety disorders, suggesting potential commonalities in their pathophysiology [1] .

Obsessive-Compulsive Disorder (OCD) was identified in 12.5% of the ADHD sample. The co-occurrence of OCD and ADHD, which may share neurobiological underpinnings, presents a diagnostic challenge, emphasizing the need for differential diagnostic criteria that can disentangle the symptomatology of these conditions.

Table 1. Gender distribution of study participants.

Table 2. Prevalence of comorbid psychiatric conditions among participants diagnosed with ADHD.

Insomnia was prevalent in 11.3% of the ADHD population, aligning with previous research that has documented disrupted circadian rhythms in individuals with ADHD, which may contribute to sleep initiation difficulties.

Post-Traumatic Stress Disorder (PTSD) was present in 8.6% of the cohort. The intersection of ADHD and PTSD, particularly in the context of early-life trauma, underscores the complex interplay between neurodevelopmental disorders and environmental stressors [2] .

Autism Spectrum Disorder (ASD) was found in 6.2% of individuals with ADHD. The symptomatic convergence of ADHD and ASD points to a potentially shared etiological basis, warranting further investigation into their common genetic and neurodevelopmental pathways [3] [4] .

Dyslexia was observed in 4.1% of the ADHD-diagnosed participants. The association between ADHD and dyslexia may be attributed to overlapping genetic vulnerabilities and neuroanatomical deviations, suggesting a syndromic relationship between these conditions.

Substance abuse was reported in 4.1% of the sample, reflecting the established link between ADHD’s impulsivity and the propensity for substance use disorders.

Bipolar Disorder was identified in 4% of the ADHD cohort. The symptomatic overlap, particularly in impulsivity, suggests a shared genetic predisposition, which could inform both diagnosis and treatment modalities.

Borderline Personality Disorder (BPD) was found in 3.5% of the ADHD sample. The commonalities in impulsivity and emotional dysregulation between BPD and ADHD highlight the necessity for clinicians to be vigilant of this comorbidity.

Dysgraphia, present in 0.6% of the cohort, and ADHD are both linked to neurodevelopmental disruptions, although the precise nature of their relationship remains to be elucidated.

The data-driven insights from this analysis contribute to a growing body of evidence that ADHD does not exist in isolation but is frequently accompanied by a range of psychiatric comorbidities. The significant gender-specific findings also prompt a re-evaluation of potential biases in the diagnosis and treatment of ADHD, advocating for a more nuanced approach that considers gender as a variable in clinical practice.

The intricate relationship between ADHD and its comorbidities invites ongoing research, particularly into the genetic, neurobiological, and environmental factors that contribute to this complexity. These findings endorse the potential benefits of early intervention strategies that could pre-empt or attenuate the development of comorbid psychiatric conditions, thereby improving the prognosis for individuals with ADHD.

4. Comorbid Conditions in Non-Binary, Transgender, and Female Individuals Diagnosed with Severe ADHD

In this cohort, the distribution of gender identity and the associated prevalence of comorbid psychiatric conditions demonstrated a notable variance. Specifically, 32 transgender individuals (12.2%), 38 non-binary individuals (10.5%), and 756 females (77.3%) were assessed through the ADHDtest.ai platform and received a diagnosis ranging from mild to severe ADHD. Detailed analysis indicated that anxiety was the most prevalent comorbid condition across non-binary (63.2%) and transgender individuals (37.5%), whereas it was the second most common in females (37.3%), just after those with no pre-existing conditions (44.97%).

Autism Spectrum Disorder (ASD) was identified in 26.3% of the non-binary group and 31.3% of the transgender group, highlighting a significant overlap with ADHD in these populations. Notably, PTSD also featured prominently, affecting 26.3% of non-binary and 25% of transgender individuals diagnosed with ADHD.

In the female cohort, comorbidities such as Obsessive-Compulsive Disorder (OCD) and Insomnia were present in 7.94% and 5.82% of individuals, respectively, while PTSD was observed in 3.17%. Less common conditions like Bipolar Disorder, Borderline Personality Disorder (BPD), and Substance Use Disorders each accounted for a smaller fraction of the cohort.

When considering ADHD without the presence of comorbid psychiatric conditions, the rates were 28.6% in transgender, 38.9% in non-binary, and 23.3% in female individuals, indicating a lower prevalence of isolated severe ADHD. These gender-related disparities in the prevalence of comorbid psychiatric conditions were statistically significant (P < 0.05), emphasizing the intricate clinical picture of severe ADHD within diverse gender identities.

5. Comorbid Conditions in Non-Binary Individuals Diagnosed with ADHD

Methodology: Data from 38 non-binary individuals diagnosed with ADHD ranging from mild to severe were collected and analysed. Each participant’s psychiatric history was reviewed to identify and quantify comorbid conditions.

Results: The prevalence of comorbid conditions such as Anxiety (63.2%), Autism (26.3%), and PTSD (26.3%) was significant. The data in Table 3 revealed notable instances of Insomnia, Dyslexia, and Dyscalculia.

Discussion: The pronounced prevalence of Anxiety among non-binary individuals with Severe ADHD, observed at 63.2%, is indicative of the heightened vulnerability to anxiety disorders within this group. The co-occurrence with Autism and Insomnia suggests a complex interplay of neurodevelopmental and psychiatric conditions that may share common etiological factors.

The data highlights the need for an intersectional perspective in mental healthcare that recognizes the unique mental health challenges of non-binary individuals. The review by Thrower et al. indicates a higher prevalence of ASD and ADHD in those with gender dysphoria, with ASD rates in transgender populations estimated at 6% - 26%, mirroring figures found in psychiatric settings.

These conditions can impact the assessment and treatment of gender dysphoria, illustrating the importance of considering neurodevelopmental disorders in gender health services. The link between ASD, ADHD, and gender dysphoria, although not fully understood, calls for further research using rigorous diagnostic criteria to enhance care for gender-diverse individuals with these conditions [5] .

6. Comorbid Conditions in Transgender Individuals Diagnosed with ADHD

Methodology: A sample of 16 transgender individuals with Severe ADHD was studied. Pre-existing psychiatric diagnoses were recorded and analysed for prevalence and patterns.

Table 3. Frequency and percentage of comorbid conditions in non-binary individuals diagnosed with ADHD.

Results: Anxiety (37.5%) and Autism (31.3%) emerged as significant comorbidities. Additionally, a substantial proportion of participants exhibited symptoms that extended beyond their Severe ADHD diagnosis.

Discussion: The findings in Table 4 underscore the intricate interplay between ADHD and psychiatric comorbidities within the transgender community. With the prevalence of anxiety and autism spectrum disorders as significant comorbidities, the data reflect a compounded vulnerability, likely intensified by the psychosocial stressors accompanying gender dysphoria and transition-related processes.

This complexity is further illuminated by research from Kaiser Permanente, which highlights that ADHD and depressive disorders are diagnosed more frequently in transgender youth than in their cisgender counterparts. According to this study, entitled “ADHD and Depressive Disorders More Frequently Diagnosed in Transgender Youth”, attention deficit disorders were found to be 3 to 7 times more common, and depressive disorders 4 to 7 times more common in transgender and gender-nonconforming youth.

The stark contrast in prevalence rates demands a reassessment of diagnostic approaches for ADHD to capture the full breadth of symptomatology in transgender individuals. Such evidence advocates for a holistic and nuanced model of care that recognizes the intersecting dimensions of gender identity and mental health, aiming to support the unique challenges faced by this community [6] .

7. Attention-Deficit/Hyperactivity Disorder (ADHD) in Females

Methods: This study conducted a comprehensive analysis of data from 756 females diagnosed with Severe ADHD to determine the frequency of comorbid conditions and to understand the clinical presentation of ADHD in this demographic.

Results: The investigation revealed that a significant number of females

Table 4. Prevalence of comorbid conditions in transgender individuals with severe ADHD.

Table 5. Comorbid conditions in females with severe ADHD.

(44.97%) had no additional psychiatric conditions, while Anxiety was the most prevalent comorbidity (37.3%). Other conditions such as OCD, Insomnia, and PTSD were also prevalent, as shown in Table 5.

Discussion: Reflecting on the clinical presentation of ADHD in women and girls, our data aligns with the findings of Quinn and Madhoo (2014)1, who underscored the unique manifestation of ADHD in this population [7] .

These research findings suggest that ADHD may manifest differently in females, with a notable portion not exhibiting additional psychiatric conditions. The high incidence of Anxiety as a comorbidity highlights the unique mental health challenges faced by females with Severe ADHD. Furthermore, the study by Quinn and Madhoo elucidates that anxiety and depression, common comorbidities in female patients with ADHD, can lead to missed or misdiagnosis. This is particularly concerning as females with ADHD who are not properly diagnosed and treated experience the same negative consequences as their male counterparts, including poor academic performance and behavioral problems.

8. Conclusions

While aligning with the National Institute of Mental Health (NIMH)’s publication on “Attention-Deficit/Hyperactivity Disorder (ADHD), this analysis extends the discourse by shedding light on the nuanced manifestations of comorbidities across different gender identities. The study corroborates the high incidence of comorbid psychiatric disorders with ADHD, as reported in the “Patient characteristics, comorbidities, and medication use for children with ADHD with and without a co-occurring reading disorder: A retrospective cohort study” study in 20112 [8] . However, this research contributes novel insights into the gender-specific prevalence and expression of these comorbidities, particularly highlighting the distinct patterns observed in female, non-binary, and transgender individuals.

The significant comorbidity percentages within the ADHD-diagnosed participants underscore the complexity of ADHD as a multifaceted condition that intersects with gender identity in ways that are not yet fully understood. The data reveals that while some comorbid conditions like anxiety and mood disorders are common across all groups, the frequency and combination of comorbidities can vary significantly, suggesting the influence of gender-related factors in the presentation and progression of ADHD.

The research emphasises the necessity for a comprehensive, gender-informed evaluative approach to ADHD, one that recognizes the unique challenges and needs of individuals across the gender spectrum. It advocates for the refinement of diagnostic criteria and treatment modalities to accommodate the diverse experiences of those with ADHD, ensuring that all individuals receive personalized care that addresses both their ADHD and the full range of associated psychiatric conditions.

The research findings underscore the imperative for ongoing scholarly investigation into the confluence of ADHD, gender, and comorbidity. This endeavour is critical for enhancing the collective comprehension of ADHD and for guiding clinical practices to accommodate the intricacies of gender in mental health. The study advocates for a more comprehensive and discerning approach to mental health care, which promises to markedly enhance the quality of life for individuals with ADHD, irrespective of gender.


*PhD Programme.

1The study by Quinn and Madhoo highlighted that ADHD in females often goes unrecognized due to a lower index of clinical suspicion, a presentation that is considered “subthreshold” due to the prominence of inattentiveness over hyperactivity/impulsivity, and the development of coping strategies that may mask symptoms.

2The 2011 study examined the differences between children with ADHD-only and those with ADHD and co-occurring reading disorder (RD), using U.S. healthcare claims data from 2005-2007. It found that those with ADHD + RD were younger, underwent more psychological testing, and had higher rates of certain comorbidities but were less likely to be prescribed stimulants. The research aimed to understand the demographic and treatment distinctions between ADHD patients with and without RD, acknowledging the limitations of using medical records for RD identification.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Palker, H.R. (2023) ADHD and Social Anxiety: Differences and Similarities. https://www.psycom.net/adhd/adhd-and-hypersexuality
[2] Cuffe, S.P., McCuUough, E.L. and Pumariega, A.J. (1994) Comorbidity of Attention Deficit Hyperactivity Disorder and Post-Traumatic Stress Disorder. https://static1.squarespace.com/static/5e5066168bf5a551ea5c4429/t/5e5169c26dd0756fb8d2b608/1582393800052/Comorbidity-AttentionDeficit-Hyperactivity-Disorder.pdf
[3] Hours, C., Recasens, C. and Baleyte, J.-M. (2022) ASD and ADHD Comorbidity: What Are We Talking About? Front Psychiatry, 13, Article ID: 837424. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8918663/
[4] Schachar, R.J., Dupuis, A., Arnold, P.D., Anagnostou, E., Kelley, E., Georgiades, S., Nicolson, R., Townes, P., Burton, C.L. and Crosbie, J. (2023) Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder: Shared or Unique Neurocognitive Profiles? Research on Child and Adolescent Psychopathology, 51, 17-31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9763138/
[5] Thrower, E., Bretherton, I., Pang, K.C., Zajac, J.D. and Cheung, A.S. (2020) Prevalence of Autism Spectrum Disorder and Attention-Deficit Hyperactivity Disorder amongst Individuals with Gender Dysphoria: A Systematic Review. Journal of Autism and Developmental Disorders, 50, 695-706. https://pubmed.ncbi.nlm.nih.gov/31732891/
[6] Permanente, K. (2018) ADHD and Depressive Disorders More Frequently Diagnosed in Transgender Youth. https://www.technologynetworks.com/neuroscience/news/adhd-and-depressive-disorders-more-frequently-diagnosed-in-transgender-youth-299702
[7] Quinn, P.O. and Madhoo, M. (2014) A Review of Attention-Deficit/Hyperactivity Disorder in Women and Girls: Uncovering This Hidden Diagnosis. https://www.psychiatrist.com/pcc/review-attention-deficit-hyperactivity-disorder-women/
[8] Classi, P.M., Le, T.K., Ward, S. and Johnston, J. (2011) Patient Characteristics, Comorbidities, and Medication Use for Children with ADHD with and without a Co-Occurring Reading Disorder: A Retrospective Cohort Study. Child and Adolescent Psychiatry and Mental Health, 5, Article No. 38. https://capmh.biomedcentral.com/articles/10.1186/1753-2000-5-38

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.