The research diagnoses of DBD and ADHD in adolescence referring to psychiatric
hospitalization – The comparison of K-SADS-PL and Finnish hospital discharge register
information
Tanja Nordström MSc1, Tuula Hurtig PhD1,2, Irma Moilanen MD, PhD2, Anja Taanila PhD1,3 and
Hanna Ebeling, MD, PhD2
1
Institute of Health Sciences, University of Oulu, Finland
2
Department of Child Psychiatry, Institute of Clinical Medicine, University and University
Hospital of Oulu, Finland
3
Unit of General Practice, University Hospital of Oulu, Finland
Correspondence: Tanja Nordström, Institute of Health Sciences, P.O. BOX 5000, FI-90014
University of Oulu, Oulu, Finland, tel. +358-40-6724730, fax. +358-8-5375661, e-mail:
tanja.nordstrom@oulu.fi
Abstract
Aim: To evaluate the occurrence of the comorbid psychiatric disorders among disruptive behavior
disorders (DBD), attention-deficit hyperactivity disorder (ADHD) or both.
Methods: The study sample (N=457) was derived from the Northern Finland Birth Cohort 1986
population. The DBD and ADHD diagnoses were defined from the K-SADS-PL interview. Four
groups were formed: adolescents with DBD (n=44), with ADHD (n=91), with both these disorders
(n=72) and without either of these disorders (n=250).The information from the Finnish Hospital
Discharge Register was used to evaluate the proportion and occurrence of psychiatric disorders
among people with DBD, ADHD or both.
Results: The adolescents with comorbid DBD & ADHD had almost 7-fold risk to have also
psychiatric disorder diagnosis in the FHDR. The risk was over 5-fold among adolescents with pure
DBD and over 2-fold among adolescents with ADHD. Also the onset age of the psychiatric
disorders in the FHDR and the combined length of the hospitalization differed among adolescents
with DBD, ADHD or both.
Conclusion: Although K-SADS-PL and FHDR both are highly valued diagnostic data sources, they
do not fully agree while comparing research diagnoses of DBD and ADHD in K-SADS-PL to
clinical psychiatric diagnoses in the FHDR.
Introduction
Very common and co-occurring psychiatric disorders among children and adolescents are disruptive
behaviour disorders (DBD) and attention deficit hyperactivity disorder (ADHD) (1). DBD consist
of two behavioural disorders: conduct disorder (CD) and oppositional defiant disorder (ODD) (2).
CD is described as a repetitive and persistent pattern of dissocial, aggressive or defiant conduct that
extends beyond ordinary levels of childish mischief or adolescent rebelliousness (3,4). ODD occurs
in younger children and is characterized by markedly defiant, disobedient, disruptive behaviour,
which do not include severe aggressive or dissocial behaviour as in CD (3,4). Childhood-onset
ADHD is characterised by symptoms of inattention, impulsivity and hyperactivity (3,4).
All these disorders are often associated with other psychiatric disorders. Comorbidity between them
is very usual and besides themselves, DBD and ADHD can for example often appear as comorbid
with depression and anxiety (1). Depression is certainly very common among people with
behavioural disorders; ICD-10 actually states depressive conduct disorder as one form of CD (4). In
a large study of 34,000 people from U.S. population (National Epidemiologic Survey on Alcohol
and Related Conditions, NESARC) CD has been showed to associate with particularly substance
use disorders, bipolar disorder, and histrionic personality disorders(5). In the same study, ADHD
was associated with increased risks of bipolar disorder, generalized anxiety disorder, post-traumatic
stress disorder, specific phobia, and narcissistic, histrionic, borderline, antisocial and schizotypal
personality disorders(6). Also ODD has been showed to precede later disorders, such as anxiety
disorders and depression (7). Kim-Cohen et al. stated that persons with anxiety, depression,
substance abuse, antisocial personality disorder, mania, schizophreniform disorder or eating
disorder at age 26 were also often diagnosed with DBD at age 15 and those with anxiety or
schizophreniform disorder at age 26 were also diagnosed with ADHD at age 15 (8).
The prospectively collected data in the Northern Finland Birth Cohort 1986 (NFBC 1986) have
made it possible to investigate the comorbidity and the occurrence of any psychiatric disorders with
DBD and/or ADHD in a population based sub-sample of Northern Finland. Previously, Hurtig et al.
found out an existing comorbidity between ADHD and CD in NFBC 1986 data, but they focused on
ADHD and left the comorbidity to be examined more thoroughly later (9). This study will expand
those findings.
A commonly used diagnostic interview to evaluate the psychopathology of the children and
adolescent is the semi-structured Schedule for Affective Disorders and Schizophrenia for SchoolAge Children, Present and Lifetime Version, K-SADS-PL. It provides DSM-IV diagnoses and is
generally considered being valid and reliable instrument (10). On the other hand, in Finland, the
National Institute for Health and Welfare maintains very comprehensive individual level hospital
discharge registers, the Finnish Hospital Discharge Register (FHDR), covering the whole country.
The FHDR includes information on all inpatient admissions to hospitals with discharge dates and
diagnoses. Registration is mandatory for all inpatient care in public and private hospitals. The
FHDR has used ICD-10 diagnoses since 1996 (ICD-9 was used during 1987–1995 and ICD-8
during 1969–1986) (11). This study will compare the information from a clinical research using KSADS-PL to the register data from the FHDR.
Our study had three study questions:
(1) How many of those who were diagnosed in ADHD research could be identified in FHDR and
does the prevalence of FHDR psychiatric disorders differ between adolescents with DBD, ADHD
or both;
(2) What was the onset age of FHDR psychiatric disorder and did the onset differ among our study
groups;
(3) Was the severity of psychiatric disorders different between the adolescents with DBD and/or
ADHD in terms of hospitalization according to the FHDR?
Material and methods
The Northern Finland Birth Cohort 1986 (NFBC 1986) is a prospective longitudinal study that
initially consisted of 9432 children born alive in northern Finland between the 1st of July, 1985 and
the 30th of June, 1986 (12). Cohort data has been collected in various occasions through postalquestionnaires, clinical examinations, and from various hospital records and national registers. The
study was approved by the Ethical Committee of The Northern Ostrobothnia Hospital District, and
was conducted in accordance with Helsinki Declaration.
The cohort was followed-up in 2001, when adolescents were 15–16 years old, with a postal
questionnaire (13). The questionnaire targeted to parents included a screening instrument for
ADHD (the Strengths and Weaknesses of ADHD Symptoms and Normal Behaviour (SWAN) scale
(14)). The adolescents were divided into three categories based on the screening results of the
SWAN score; to likely ADHD-cases whose scores exceeded the upper 95th percentile on either
combined, inattentive or hyperactive-impulsive -scales, to controls whose scores were below 90th
percentile in all scales and to those who belonged neither of above categories. To conduct a clinical
study focused on ADHD, 802 adolescents from likely case and control -categories were contacted
(13). A total of 457 adolescents participated and their current and lifetime psychiatric diagnoses
were obtained via the K-SADS-PL, conducted by masters-level interviewers with the adolescents
and their parents. Based on this, the study sample was divided into four groups (Figure 1): those
who have been diagnosed with (a) only DBD, (b) only ADHD, (c) both DBD and ADHD and (d) no
DBD or ADHD group.
-------------------------- Figure 1
The psychiatric diagnosis information was also obtained via the FHDR which contains information
on all hospital treatments, including psychiatric diagnoses, in Finland. We linked information in the
FHDR for the participants in the NFBC 1986 using the unique personal identification number given
to all Finnish residents and used in all national registers. All psychiatric disorders (ICD-10 codes
F00–F99 and ICD-9 codes 290–319) from the birth to the end of 2010 were included. The register
information contained also the time of admission and the length of the hospitalization. The
psychiatric diagnosis (ICD-8 290–315, ICD-9 290–319 and ICD-10 F00–F99) information of the
parents until 2010 was also obtained.
The information about the family structure was obtained from the postal questionnaire made to the
mothers when the children were 7 years old (15). It was classified as one of three categories:
biological parents (always two biological parents), a blended family (one biological parent and a
new partner) and a single-parent family (one biological divorced, separated or widowed parent or
the mother had never been married or cohabitated with child’s father)
Statistical analysis
All statistical analyses were completed by R, version 2.13.1 (2011, The R Foundation for Statistical
Computing) and IBM SPSS Statistics, version 19 (1989, 2010 SPSS, Inc., an IBM company). The
multinomial logistic regression was used to evaluate the associations between the diagnoses based
on the K-SADS-PL and FHDR data and also between study groups and parental psychiatric history,
gender and family structure at 7 year. The associations between other psychiatric disorders and
DBD, ADHD and DBD & ADHD were examined with contingency tables and tested with Fisher’s
exact test. The onset age of psychiatric disorder between the study groups was evaluated with
Kaplan-Meier survival analysis and Breslow (Generalized Wilcoxon) test. The length of the
hospitalization among people with DBD and/or ADHD was explored with Kruskal–Wallis one-way
analysis of variance.
Results
In the current study population, according to K-SADS-PL, there were 44 (9.6%) adolescents who
had been diagnosed with only DBD, 91 (19.9%) with only ADHD, 72 (15.6%) people with
comorbid DBD and ADHD, and 250 (54.7%) people without either of these two diagnoses. The
gender distribution among these disorders was statistically significant (χ2 = 19.1, df = 3, p < 0.001).
Males were the majority among all other groups than in the DBD –group, where 61.4% were
females (Fig. 1).
The register based psychiatric diagnoses were then obtained from the FHDR data. 42 (9.2%) people
of the study population had one or more hospital admissions. Over 22% of those who were
diagnosed with comorbid DBD and ADHD as adolescent had also register based diagnosis. 18% of
adolescents who were diagnosed with only DBD were as well obtained entry in the FHDR data and
even among those who were diagnosed with only ADHD the percentage (9%) of the register based
diagnosis was larger than in the no diagnosis –group (4%). Table 1 shows the multinomial logistic
regression models about the associations between the diagnosis based on the K-SADS-PL and
FHDR data. The results were similar in both unadjusted and adjusted models. Adolescents
belonging to the comorbid DBD & ADHD –group had almost 7-fold risk to have also psychiatric
disorder diagnosis in the FHDR data. The risk was over 5-fold in the DBD –group and over 2-fold
on ADHD –group, however the association was not statistically significant in the latter. Similar
results were observed also among adjusted models.
------------ Table 1.
Table 1 also shows the associations between study groups and parental psychiatric history, gender
and family structure at 7 year. 53 (11.6%) of the fathers and 28 (6.1%) of the mothers were also
diagnosed with some psychiatric diagnosis in the FHDR. The paternal diagnosis in the FHDR data
seemed to associate to the pure DBD –group. The gender distribution was statistically significant
among pure DBD and pure ADHD –groups. Single parent family associated with the comorbid
DBD & ADHD –group.
Table 2 shows the proportions of the psychiatric disorder diagnosis from the FHDR data among
adolescents with DBD and/or ADHD separated by the ICD-10 and ICD-9 classifications. The
numbers are low but the differences are visible, especially in the comorbid group. Among
adolescents with DBD, there was no clear concentration of FHDR diagnosis as was also in the
ADHD –group. In the comorbid group, however, statistically significant associations appealed in
various categories. Also worth of noticing is the lack of ICD-10 behavioural and emotional
disorders in the ADHD –group.
----------------Table 2.
We then evaluated the age of onset of the psychiatric disorders in FHDR data. The age range was
from 2.3 to 24.7 years with median age being 14.1 (IQR = 7.2–19.5) years. Figure 2 describes the
first occurrence of the first psychiatric disorder entry in FHDR divided among our study groups.
Figure shows clearly different onset of other psychiatric disorders based on the study groups. The
Breslow (Generalized Wilcoxon) test of equality of survival distributions was statistically
significant (χ2 = 26.4, df = 3, p < 0.001) indicating strong differences between the groups. The
pairwise comparisons also showed that the DBD –group differed with statistical significance from
the no diagnosis –group (p < 0.001) as well did the comorbid DBD & ADHD –group (p < 0.001).
The pure ADHD –group did not differ as strongly but still showed a trend towards the statistical
significance (p = 0.078).
--------------Figure 2.
Finally, we studied the combined length of the hospital treatments resulting from any psychiatric
disorders, obtained from the FHDR data. All the admissions were combined to count the sum of the
days spent in psychiatric hospitals as inpatient. The total sum varied from 0 to 717 days (median =
30, IQR = 4–85). Adolescents in the DBD –group, with also FHDR diagnosis, were admitted to
psychiatric hospital from 0 to 141 days (median = 25, IQR = 1–115), in ADHD –group from 4 to
115 days (median = 50, IQR = 17–107) and in the comorbid DBD & ADHD –group from 0 to 717
days (median = 26, IQR = 16–110). When compared to no diagnosis group (admissions varying
from 0 to 114, median = 4, IQR = 1–61) all our groups had longer combined hospital admissions.
This was also tested with the Kruskal-Wallis test but due the small number of the people with
hospital admissions the test did not reach the statistical significance (DBD: p = 0.623, ADHD: p =
0.089, DBD & ADHD: p = 0.077).
Discussion
This study expanded previous results of the comorbidity of ADHD in the NFBC 1986 cohort,
compared the information gained from the K-SADS-PL to the FHDR information, and answered the
questions concerning the differences in FHDR data between adolescents diagnosed with only DBD,
with only ADHD and with both DBD and ADHD.
We found the proportion of psychiatric diagnosis in the FHDR data larger in all three behavioural
diagnosis groups compared to adolescents without such diagnosis in K-SADS-PL interview. Also
the occurrence of diagnoses in FHDR data differed between these groups. The combined length of
the hospital treatments differed between the groups.
The K-SADS-PL diagnostic interview is widely used to evaluate the psychiatric morbidity of 6–18
–years old children and adolescents worldwide. For example to evaluate the behavioural problems
of adolescents, it has been used in various studies. Previous study in the NFBC 1986 (9) found
ADHD to be comorbid with CD, ODD, substance abuse and mild depression. Malmberg et al. (16)
found subthreshold diagnoses of DBD and ADHD to be as risk factors for various other psychiatric
symptoms. Huh et al.(17) used Korean version of K-SADS-PL to evaluate the comorbidity among
ADHD and found that the psychiatric comorbidity may differ between adolescents and children.
Recently, Ilomäki et al. (18) studied the gender differences in comorbidity of CD among psychiatric
inpatients in Northern Finland using K-SADS-PL and concluded that girls with CD seemed to have
an increased tendency to develop comorbid psychiatric disorders.
The FHDR is one of the oldest individual level hospital discharge registers including the
information of all in the whole country in the world, which quality is considered good and validity
high. Sund (11) reviews several studies validating the FHDR information and concludes the
completeness and accuracy in the register varying from satisfactory to very good. However, despite
many studies comparing FHDR data to other information, there is no study that compares FHDR to
K-SADS-PL, especially trough DBD and/or ADHD.
The prevalence of K-SADS-PL behavioural disorders in our study population was quite high; this is
explained by the formation of the sample, which was conducted to examine ADHD (13). However,
this arrangement provides an excellent opportunity to examine also DBD and the comorbidity
between DBD and ADHD.
The boys are usually the majority among adolescents diagnosed with DBD (19): in our study it was
opposite. This interesting gender difference between disorders in our study population could be
explained by the fact that the study sample is rather small which increases the role of coincidence;
also most of the boys were diagnosed with both DBD and ADHD while most of the girls were
diagnosed with only DBD.
When comparing the FHDR information to K-SADS-PL diagnoses, the proportion of psychiatric
disorder in FHDR was larger in all behavioural groups but it was not as high as it could be expected
if the diagnoses from both sources would be valid. However, it is important to notice that these
disorders do not always need hospitalization and could be treated in outpatient clinics, which does
not show in the FHDR data. Also only people with the most severe behavioural symptoms are
admitted to hospitals and therefore the milder cases are not represented in the FHDR data. The lack
of ICD-10 behavioral and emotional disorders in the ADHD –group could be originating from that
fact. Also the differences between the ICD-10 diagnoses used in FHDR and DSM-IV diagnoses that
K-SADS-PL uses should be taken into account. Regardless, the behavioural groups clearly
increased the risk to obtain also FHDR diagnosis during one’s life, especially in pure DBD and
comorbid DBD and ADHD –groups. This answers the research question one.
The FHDR information used in the present study extends to year 2010 when the study subjects were
24-25 years old. Although many of the psychiatric disorders usually first occur in childhood or
adolescence, there are disorders that have also later age of onset, for example anxiety and mood
disorders (20). Therefore, there might be some psychiatric disorders unnoticed in our study
population. Fortunate, the NFBC 1986 data provides the opportunity to continue this research to
verify and expand our findings. However, with the currently available data we showed that the age
of onset of psychiatric diagnoses between our behavioural groups differed from each other. This
contains the answer to research question two.
To answer the research question number three, we must interpret the results containing information
of the combined length of the hospital treatments. Probably due the small number of adolescents
with psychiatric hospitalization the statistical test did not reach the significance but while observing
the lengths of the admissions between the groups, the differences are clear compared to no
behavioural diagnosis group.
As a conclusion, this study expanded previous results about the comorbidity of ADHD in the NFBC
1986 and compared the information gained from the K-SADS-PL to the FHDR information. We
found that although K-SADS-PL and FHDR both are highly valued diagnostic data sources, they do
not fully agree while comparing research diagnoses of DBD and ADHD in K-SADS-PL to clinical
psychiatric diagnoses in the FHDR. The results obtained in this study are significant in sense of
comparing epidemiological studies into clinical samples.
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Figure 1. The chart of the participation flow.
Figure 2. The first occurrence of the other psychiatric disorders among adolescents with DBD,
ADHD or DBD & ADHD.
0.25
The proportion of mental disorders according to FHDR
Diagnosis based on K-SADS-PL at age 16
None
DBD
ADHD
Comorbid DBD & ADHD
0.20
0.15
0.10
0.05
0.00
0
5
10
15
The age of the participants (years)
20
25
Table 1: The multinomial logistic regression model about the associations between the diagnosis based on the K-SADS-PL and FHDR data with
both unadjusted and adjusted models.
Diagnosis based on K-SADS-PL at age 16
none
(N=250)
n (%)
n (%)
10 (4.0)
8 (18.2)
Father diagnosed
21 (8.4)
11 (25.0)
Mother diagnosed
15 (6.0)
3 (6.8)
Male
155 (62.0)
17 (38.6)
0.4 (0.2-0.7) 0.005
0.4 (0.2-0.7) 0.004
70 (76.9)
2.0 (1.2-3.5) 0.011
1.9 (1.1-3.3) 0.027
47 (65.3)
1.2 (0.7-2.0) 0.612
0.9 (0.5-1.7) 0.851
Female
95 (38.0)
27 (61.4)
1
21 (23.1)
1
25 (34.7)
1
205 (85.4)
35 (85.7)
1
71 (82.6)
1
49 (75.4)
1
Blended family
21 (8.8)
4 (9.5)
Single parent
14 (5.8)
2 (4.8)
Diagnosis of any psychiatric
disorder in FHDR
DBD (N=44)
OR (95% CI) p
AdjOR (95% CI) p
5.3 (2.0-14.4) 0.001
4.4 (1.8-14.2) 0.006
ADHD (N=91)
n (%)
8 (8.8)
OR (95% CI) p
AdjOR (95% CI) p
2.3 (0.9-6.1) 0.088
2.2 (0.8-5.9) 0.111
DBD & ADHD (N=72)
n (%)
16 (22.2)
OR (95% CI) p
AdjOR (95% CI) p
6.9 (3.0-15.9) <0.001
5.6 (2.2-13.8) <0.001
Parental psychiatric history
3.6 (1.6-8.2) 0.002
4.0 (1.6-9.7) 0.002
1.1 (0.3-4.1) 0.835
1.1 (0.3-4.4) 0.932
13 (14.3)
3 (3.3)
1.8 (0.8-3.8) 0.113
1.8 (0.8-4.2) 0.140
0.5 (0.2-1.9) 0.331
0.3 (0.1-1.6) 0.166
8 (11.1)
7 (9.7)
1.4 (0.6-3.2) 0.480
1.3 (0.5-3.4) 0.533
1.7 (0.7-4.3) 0.275
2.0 (0.7-5.8) 0.187
Gender
Family type at 7 years
Both biological parents
1.1 (0.4-3.3) 0.888
0.6 (0.1-3.2) 0.614
0.8 (0.2-3.7) 0.791
0.7 (0.1-3.2) 0.614
8 (9.3)
7 (8.1)
1.1 (0.5-2.6) 0.828
1.0 (0.4-2.6) 0.949)
1.4 (0.6-3.7) 0.447
1.3 (0.5-3.4) 0.596
3 (4.6)
13 (20.0)
0.6 (0.2-2.1) 0.419
0.4 (0.1-1.6) 0.190
3.9 (1.7-8.8) 0.001
3.5 (1.5-8.1) 0.004
Table 2: The proportions of psychiatric disorders from FHDR compared with Fisher’s Exact test.
ICD-10 categories
Organic, including symptomatic, mental disorders F00-F09
Mental and behavioural disorders due to psychoactive substance use F10F19
Schizophrenia, schizotypal and delusional disorders F20-F29
Mood (affective) disorders F30-F39
Neurotic, stress-related and somatoform disorders F40-F48
Behavioural syndromes associated with physiological disturbances and
physical factors F50-F59
Disorders of adult personality and behavior F60-F69
Mental retardation F70-F79
Disorders of psychological development F80-F89
Behavioural and emotional disorders with onset usually occurring in
childhood and adolescence F90-F98
Unspecified mental disorder F99
ICD-9 categories
Psychosis 290-299
Neurotic disorders, personality disorders, and other nonpsychotic mental
disorders 300-316
none
(N=250)
DBD
(N=44)
ADHD
(N=91)
n (%)
n (%) p
n (%) p
DBD &
ADHD
(N=72)
n (%) p
0 (0.0)
0 (0.0) -
0 (0.0) -
0 (0.0) -
1 (0.4)
1 (2.3) 0.277
1 (1.1) 0.464
6 (8.3) 0.001
0 (0)
3 (1.2)
4 (1.6)
1 (2.3) 0.150
1 (2.3) 0.479
1 (2.3) 0.558
1 (1.1) 0.268
3 (3.3) 0.197
1 (1.1) 1.000
1 (1.4) 0.224
6 (8.3) 0.005
5 (6.9) 0.030
0 (0.0)
0 (0.0) -
0 (0.0) -
0 (0.0) -
1 (0.4)
0 (0.0)
0 (0.0)
1 (2.3) 0.277
0 (0.0) 1 (2.3) 0.150
1 (1.1) 0.464
0 (0.0) 1 (1.1) 0.268
2 (2.8) 0.127
0 (0.0) 1 (1.4) 0.224
1 (0.4)
2 (4.5) 0.060
0 (0.0) 1.000
5 (6.9) 0.003
0 (0.0)
0 (0.0) -
0 (0.0) -
0 (0.0) -
0 (0)
1 (2.3) 0.150
1 (01.1) 0.268
1 (1.4) 0.224
6 (2.4)
3 (6.8) 0.137
4 (4.4) 0.467
6 (8.3) 0.031