Suicidality and Self-harm in Adolescents With Attention-Deficit/Hyperactivity Disorder and Subsyndromal ADHD

Abstract

Self-harm and suicidality (ideation and attempts) are common in adolescents. In a nationally representative study, approximately 8%, 7.5%, and 2.4% of 12- to 17-year-old Australians engaged in self-harm, suicidal ideation, or a suicide attempt, respectively, in the previous 12 months.1Lawrence D Johnson S Hafekost J et al.The mental health of children and adolescents: Report on the Second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Department of Health, Canberra2015Google Scholar Adolescents with a diagnosable mental health disorder had significantly increased risk of self-harm and suicidality.1Lawrence D Johnson S Hafekost J et al.The mental health of children and adolescents: Report on the Second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Department of Health, Canberra2015Google Scholar It is well established that adolescents with attention-deficit/hyperactivity disorder (ADHD) have elevated risk for suicidality.2Balazs J Kereszteny A. Attention-deficit/hyperactivity disorder and suicide: A systematic review.World Journal of Psychiatry. 2017; 7: 44Crossref PubMed Google Scholar Mounting evidence indicates that adolescents with subsyndromal ADHD (elevated symptoms of ADHD but not meeting full diagnostic threshold) experience impairments similar to those with full ADHD.3Kirova AM Kelberman C Storch B et al.Are subsyndromal manifestations of attention deficit hyperactivity disorder morbid in children? A systematic qualitative review of the literature with meta-analysis.Psychiatry Res. 2019; 274: 75-90Crossref PubMed Scopus (21) Google Scholar Only one study to date has investigated suicidality in subsyndromal ADHD.4Fergusson DM Boden JM Horwood LJ. Classification of behavior disorders in adolescence: Scaling methods, predictive validity, and gender differences.J Abnorm Psychol. 2010; 119: 699Crossref PubMed Scopus (59) Google Scholar Fergusson et al.4Fergusson DM Boden JM Horwood LJ. Classification of behavior disorders in adolescence: Scaling methods, predictive validity, and gender differences.J Abnorm Psychol. 2010; 119: 699Crossref PubMed Scopus (59) Google Scholar reported a linear increase in number of suicide attempts across participants without ADHD, with subsyndromal ADHD, and with threshold ADHD; however, they did not examine suicidal ideation or self-harm. In this study, we compared rates of self-harm, suicidal ideation, and suicide attempts in Australian adolescents with ADHD and subsyndromal ADHD and in non-ADHD controls. We used data from Young Minds Matter, a nationally representative sample of Australian youths (age range, 4–17 years) and their parents,1Lawrence D Johnson S Hafekost J et al.The mental health of children and adolescents: Report on the Second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Department of Health, Canberra2015Google Scholar to estimate the population prevalence of self-harm and suicidality in adolescents with ADHD or subsyndromal ADHD (3–5 symptoms of inattention or hyperactivity/impulsivity plus impaired functioning) compared with non-ADHD controls. In 2013–2014, parents completed the Diagnostic Interview Schedule for Children–Version IV (DISC-IV)5Shaffer D Fisher P Lucas C Dulcan M Schwab-Stone M. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): Description, differences from previous versions, and reliability of some common diagnoses.J Am Acad Child Adolesc Psychiatry. 2000; 39: 28-38Abstract Full Text Full Text PDF PubMed Scopus (2700) Google Scholar and answered questions about health service use, and adolescents (age range, 12–17 years; N = 2,653) completed a questionnaire about self-harm and suicidal thoughts and behaviors in the previous 12 months and lifetime (see Supplement 1, available online).1Lawrence D Johnson S Hafekost J et al.The mental health of children and adolescents: Report on the Second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Department of Health, Canberra2015Google Scholar The study was ethically approved, and the de-identified dataset is publicly available. We used multinomial regression analyses to calculate odds ratios (ORs) with 95% CIs comparing the 2 ADHD groups with each other and with the non-ADHD controls on self-harm, suicidality, and service use. Analyses adjusted for age, sex, and both threshold and subsyndromal comorbidities (anxiety, depression, and conduct disorder) (see S1, available online, for the relationship between confounders and suicidality and self-harm). The sample characteristics are shown in Table 1. There were 174 adolescents who met full DSM-IV criteria for ADHD, 547 adolescents with subsyndromal ADHD, and 1,932 non-ADHD controls. Adolescents with ADHD and subsyndromal ADHD did not differ on any measure of self-harm or suicidality. Adolescents with ADHD and subsyndromal ADHD were more likely to have ever had suicidal thoughts compared with non-ADHD controls (Table 2). Adolescents with ADHD were more likely to have made a suicide attempt, while adolescents with subsyndromal ADHD had increased odds of ever having self-harmed. There was no difference between the 3 groups in relation to self-harm or suicide attempt in the past 12 months. Adolescents with ADHD and subsyndromal ADHD were more likely than non-ADHD controls to have accessed health services in the previous 12 months (OR = 5.23, 95% CI 3.56–7.68, p < .001; OR = 2.81, 95% CI 2.18–3.62, p < .001), and adolescents with subsyndromal ADHD were less likely to access services than adolescents with ADHD (OR = 0.58, 95% CI 0.39–0.85, p = .006).TABLE 1Sample Characteristics of Adolescents With Attention-Deficit/Hyperactivity Disorder (ADHD), Subsyndromal ADHD, and Non-ADHD ControlsNo ADHD (n = 1,932)Subsyndromal ADHD (n = 547)ADHD (n = 174)Sex, male (%)907 (47.0)329 (60.2)133 (76.4)Age, y, mean (SD)15.09 (1.71)14.85 (1.73)14.48 (1.80)Socioeconomic status quintilesaThe 5 quintiles each comprise 20% of areas ranked by socioeconomic status from the most disadvantaged (lowest quintile) to least disadvantaged (highest quintile). 1st (lowest), (%)269 (13.9)99 (18.1)34 (19.5) 2nd, (%)339 (17.6)88 (16.1)47 (27.0) 3rd, (%)407 (21.1)122 (22.3)33 (19.0) 4th, (%)437 (22.6)109 (19.9)31 (17.8) 5th (highest), (%)480 (24.8)129 (23.6)29 (16.7)Country of birth Australia, (%)1,619 (83.8)494 (90.3)166 (95.4) Overseas, (%)313 (16.2)53 (9.7)8 (4.6)Major depressive disorder (parent report), (%)48 (2.5)86 (15.7)22 (12.6)Major depressive disorder (youth report), (%)167 (8.6)90 (16.5)21 (12.1)Any anxiety disorder, (%)89 (4.6)97 (17.7)41 (23.6)Conduct disorder, (%)6 (0.3)24 (4.4)21 (12.1)Service usebParent report of adolescent using any heath service for emotional or behavioral problem in the previous 12 months.265 (13.7)217 (39.7)91 (52.3)Note: Information on race/ethnicity was not collected in Young Minds Matter as it is not typical to collect these data in Australian research.a The 5 quintiles each comprise 20% of areas ranked by socioeconomic status from the most disadvantaged (lowest quintile) to least disadvantaged (highest quintile).b Parent report of adolescent using any heath service for emotional or behavioral problem in the previous 12 months. Open table in a new tab TABLE 2Prevalence and Adjusted Odds Ratios (95% CI) for Self-harm and Suicidality in Adolescents With Attention-Deficit/Hyperactivity Disorder (ADHD) and Subsyndromal ADHD Compared With Non-ADHD Controlsn (%)AOR95% CIpSelf-harm ever Controls (reference)203 (11.3)——— ADHD23 (14.2)1.260.69–2.27.451 Subsyndromal ADHD102 (20.9)1.581.12–2.23.009Self-harm past 12 monthsaAsked only if yes to ever self-harmed. Controls (reference)150 (73.9)——— ADHD15 (65.2)0.770.26–2.24.629 Subsyndromal ADHD76 (74.5)0.810.43–1.50.495Suicidal thoughts ever Controls (reference)465 (24.1)——— ADHD58 (33.3)1.691.12–2.55.012 Subsyndromal ADHD208 (38.0)1.661.29–2.14< .001Suicidal thoughts past 12 months Controls (reference)129 (7.0)——— ADHD19 (11.7)1.340.68–2.67.399 Subsyndromal ADHD72 (14.3)1.210.80–1.85.366Suicide plan past 12 monthsbAsked only if yes to considered suicide in last 12 months. Controls (reference)86 (66.7)——— ADHD14 (73.7)1.660.48–5.72.423 Subsyndromal ADHD54 (75.0)1.260.60–2.64.543Suicide attempt everb Controls (reference)46 (35.7)——— ADHD13 (68.4)3.511.10–11.27.035 Subsyndromal ADHD39 (54.2)1.580.82–3.06.174Suicide attempt past 12 monthscAsked only if yes to ever attempted suicide. Controls (reference)31 (67.4)——— ADHD11 (84.6)2.300.37–14.43.373 Subsyndromal ADHD32 (82.1)1.400.43–4.55.573Note: Analyses adjust for adolescent sex, age, any anxiety disorder, conduct disorder, and parent- and youth-reported major depressive disorder. Both parent and youth reports of major depressive disorder were included in analyses as there was low correspondence between raters (intraclass correlation coefficient = 0.32, 95% CI 0.28–0.35). AOR = adjusted odds ratio.a Asked only if yes to ever self-harmed.b Asked only if yes to considered suicide in last 12 months.c Asked only if yes to ever attempted suicide. Open table in a new tab TABLE S1Adjusted Odds Ratios (95% CI) for Self-harm and Suicidality for Confounding Variables Included in Primary AnalysisAOR95% CIpSelf-harm ever Sex, female2.231.66–3.00< .001 Age1.151.05–1.25.002 MDD, parent report2.051.22–3.46.007 Subsyndromal MDD, parent report1.520.89–2.59.124 MDD, youth report18.2812.88–25.95< .001 Subsyndromal MDD, youth report3.962.61–6.02< .001 Anxiety disorder0.820.51–1.33.427 Conduct disorder1.560.64–3.81.333 Subsyndromal conduct disorder2.931.19–7.17.019Self-harm past 12 monthsaAsked only if yes to ever self-harmed. Sex, female1.901.09–3.33.024 Age0.850.71–1.03.095 MDD, parent report2.190.84–5.68.108 Subsyndromal MDD, parent report1.280.52–3.20.591 MDD, youth report3.551.92–6.55< .001 Subsyndromal MDD, youth report3.251.35–7.80.009 Anxiety disorder1.050.45–2.44.918 Conduct disorder0.670.14–3.40.648 Subsyndromal conduct disorder0.660.17–2.57.549Suicidal thoughts ever Sex, female1.741.42–2.14< .001 Age1.131.07–1.20< .001 MDD, parent report1.981.26–3.13.003 Subsyndromal MDD, parent report1.591.04–2.44.033 MDD, youth report15.5711.01–22.03< .001 Subsyndromal MDD, youth report5.123.73–7.05< .001 Anxiety disorder0.990.67–1.45.951 Conduct disorder1.370.70–2.69.352 Subsyndromal conduct disorder1.600.76–3.36.216Suicidal thoughts past 12 months Sex, female1.671.15–2.41.007 Age1.010.90–1.12.913 MDD, parent report4.372.48–7.70< .001 Subsyndromal MDD, parent report2.491.42–4.37.001 MDD, youth report32.5021.63–48.82< .001 Subsyndromal MDD, youth report6.013.64–9.93< .001 Anxiety disorder0.490.28–0.86.013 Conduct disorder2.290.90–5.84.082 Subsyndromal conduct disorder3.071.16–8.18.024Suicide plan past 12 monthsbAsked only if yes to considered suicide in last 12 months. Sex, female0.910.45–1.83.791 Age0.920.74–1.15.479 MDD, parent report0.840.33–2.12.705 Subsyndromal MDD, parent report0.730.29–1.85.511 MDD, youth report6.072.82–13.07< .001 Subsyndromal MDD, youth report1.860.71–4.84.205 Anxiety disorder1.020.40–2.60.973 Conduct disorder3.540.39–31.85.260 Subsyndromal conduct disorder1.180.28–5.01.819Suicide attempt everbAsked only if yes to considered suicide in last 12 months. Sex, female0.650.33–1.27.208 Age1.020.83–1.27.832 MDD, parent report1.210.54–2.72.638 Subsyndromal MDD, parent report1.110.48–2.57.814 MDD, youth report3.511.60–7.67.002 Subsyndromal MDD, youth report1.790.64–5.02.271 Anxiety disorder1.090.48–2.47.837 Conduct disorder8.650.98–76.19.052 Subsyndromal conduct disorder1.820.49–6.76.369Suicide attempt past 12 monthscAsked only if yes to ever attempted suicide. Sex, female0.930.30–2.93.903 Age0.770.53–1.12.171 MDD, parent report8.501.46–49.39.017 Subsyndromal MDD, parent report1.720.42–7.02.448 MDD, youth report1.650.39–7.04.497 Subsyndromal MDD, youth report4.130.42–40.55.224 Anxiety disorder1.140.24–5.48.874 Conduct disorder0.650.09–4.59.663 Subsyndromal conduct disorder1.600.14–18.00.703Note: Analyses adjust for adolescent sex, age, any anxiety disorder, conduct disorder, and parent- and youth-reported MDD. Both parent and youth reports of MDD were included in analyses as there was low correspondence between raters (intraclass correlation coefficient = 0.32, 95% CI 0.28–0.35). AOR = adjusted odds ratio; MDD = major depressive disorder.a Asked only if yes to ever self-harmed.b Asked only if yes to considered suicide in last 12 months.c Asked only if yes to ever attempted suicide. Open table in a new tab Note: Information on race/ethnicity was not collected in Young Minds Matter as it is not typical to collect these data in Australian research. Note: Analyses adjust for adolescent sex, age, any anxiety disorder, conduct disorder, and parent- and youth-reported major depressive disorder. Both parent and youth reports of major depressive disorder were included in analyses as there was low correspondence between raters (intraclass correlation coefficient = 0.32, 95% CI 0.28–0.35). AOR = adjusted odds ratio. Note: Analyses adjust for adolescent sex, age, any anxiety disorder, conduct disorder, and parent- and youth-reported MDD. Both parent and youth reports of MDD were included in analyses as there was low correspondence between raters (intraclass correlation coefficient = 0.32, 95% CI 0.28–0.35). AOR = adjusted odds ratio; MDD = major depressive disorder. There were no differences in reported self-harm or suicidal thoughts, plans, or attempts between adolescents with ADHD, subsyndromal ADHD, or no ADHD over the preceding 12 months. However, compared with participants with no ADHD, lifetime rates of suicidal thoughts were similarly increased in both adolescents with ADHD and adolescents with subsyndromal ADHD. There were no statistically significant differences in any aspects of self-harm or suicidality between the ADHD and subsyndromal ADHD groups. However, adolescents meeting full ADHD criteria had increased lifetime rates of suicide attempts compared with non-ADHD controls, and adolescents with subsyndromal ADHD had increased rates of self-harm compared with non-ADHD controls. These findings have important clinical implications. Clinicians working with adolescents need to be aware of the potential increased suicidal risk for adolescents with significant ADHD symptoms even when they do not meet full ADHD diagnostic criteria. These data provide further evidence of the importance of considering ADHD as a dimensional presentation. Further, adolescents with subsyndromal presentations are less likely to be engaged with clinical services, emphasizing the need for increased community awareness and promotion of services within schools and community settings to improve support for adolescents with subsyndromal presentations and, where appropriate, engagement with clinical services. A key strength of these data is that they are nationally representative; however, being a community-based sample, the number of participants who had attempted suicide in the previous 12 months was small and reduced the likelihood of identifying group differences at this level of analysis. Self-Harm Ask if Age ≥12 Years Sometimes people feel so depressed and hopeless about the future that they may consider hurting or injuring themselves. These next questions ask about deliberate self-harm, that is, deliberately hurting or injuring yourself without trying to end your life. YRB34. Have you ever deliberately done something to yourself to cause harm or injury, without intending to end your own life? 2 – Yes 0 – No 7 – Prefer not to say Ask if Age ≥12 Years and YRB34 = 2 YRB35. Have you deliberately harmed or injured yourself without intending to end your own life during the past 12 months? 2 – Yes 0 – No Suicide Ask if Age ≥12 Years These next questions ask about suicide or attempting suicide, that is, taking some action to try to end your own life. YRB40. Have you ever felt life was not worth living? 2 – Yes 0 – No YRB41. During the past 12 months, did you ever seriously consider attempting suicide? 2 – Yes 0 – No 7 – Prefer not to say Ask if Age ≥12 Years and YRB41 = 2 YRB42. During the past 12 months, did you make a plan about how you would attempt suicide? 2 – Yes 0 – No YRB43. Have you ever actually attempted suicide? 2 – Yes 0 – No Ask if Age >= 12 Years and YRB43 = 2 YRB44. Did you attempt suicide during the past 12 months? 2 – Yes 0 – No