Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder

Abstract

Context: Major depression and dysthymia in adolescence are associated with substantial disability, need for mental health services, and risk for recurrence. Concrete suicidal ideation and attempts during adolescence are particularly associated with significant distress, morbidity, and risk for completed suicide.

Objectives: To test the hypothesis that young children with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for depression and suicidal ideation and attempts during adolescence and to identify early predictors of which young children with ADHD are at greatest risk.

Design: Prospective follow-up study.

Setting: Chicago, Illinois, and Pittsburgh, Pennsylvania. Patients A cohort of 125 children who met DSM-IV criteria for ADHD at 4 to 6 years of age and 123 demographically matched comparison children without ADHD were prospectively followed up in 7 structured diagnostic assessments of depression and suicidal behavior in assessment years 6 through 14, spanning 9 through 18 years of age.

Main outcome measures: DSM-IV criteria for depressive disorders and suicidal behavior.

Results: Children with ADHD at 4 to 6 years of age were at greatly increased risk for meeting DSM-IV criteria for major depression or dysthymia (hazard ratio, 4.32) and for attempting suicide (hazard ratio, 3.60) through the age of 18 years relative to comparison children. There were marked variations in risk for these outcomes among children with ADHD, however. Within the ADHD group, children with each subtype of ADHD were at risk but for different adverse outcomes. Girls were at greater risk for depression and suicide attempts. Maternal depression and concurrent child emotional and behavior problems at 4 to 6 years of age predicted depression and suicidal behavior.

Conclusions: All subtypes of ADHD in young children robustly predict adolescent depression and/or suicide attempts 5 to 13 years later. Furthermore, female sex, maternal depression, and concurrent symptoms at 4 to 6 years of age predict which children with ADHD are at greatest risk for these adverse outcomes. Identifying high-risk young children with ADHD sets the stage for early prevention trials to reduce risk for later depression and suicidal behavior.

Figure 1

Survival probabilities for (A) the diagnosis of major depression and/or dysthymia and (B) suicide attempts during assessment years 6 through 14 (spanning 9-18 years of age) among 125 children and adolescents with attention-deficit/hyperactivity disorder (ADHD) in year 1 and 123 comparison children and adolescents.

Figure 2

Survival probabilities for (A) the diagnosis of major depression and/or dysthymia and (B) suicide attempts during assessment years 6 through 14 (spanning 9-18 years of age) among comparison children and adolescents (n=123; 0) and children and adolescents who met criteria for the combined (n=85; 1), predominantly hyperactive-impulsive (n=27; 2), or predominantly inattentive (n=13; 3) subtypes of attention-deficit/hyperactivity disorder in year 1.

Figure 3

Survival probabilities for (A) the diagnosis of major depression and/or dysthymia and (B) suicide attempts during assessment years 6 through 14 (spanning 9-18 years of age) among boys (n=107) (1) and girls (n=18) (2) with attention-deficit/hyperactivity disorder in year 1.

Figure 4

Association between the total number of depression, anxiety, oppositional defiant disorder, and conduct disorder symptoms in assessment year 1 and their meeting diagnostic criteria for depression at least once during assessment years 6 through 14 among the 125 children who met criteria for attention-deficit/hyperactivity disorder in year 1. MDD indicates major depressive disorder.