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COMORBIDITY OF MENTAL ILLNESS AMONG CHILDREN WITH DISABILITIES

BY H. BARRY WALDMAN, DDS, MPH, PHD, RICK RADER, MD, DHL (HON), AND STEVEN P. PERLMAN, DDS, MSCD, DHL (HON)

WHAT IS IT?

"Comorbid - existing simultaneously with and usually independently of another medical condition." 1 "Comorbidity is associated with worse health outcomes, more complex clinical management, and increased health care costs." 2

The term is used for children and adults with developmental disabilities along with co-occurring mental illness and behavioral difficulties. For example, when a youngster with developmental and behavioral difficulties is examined, it can be difficult to determine the underlying cause of these difficulties. In addition, because of their cognitive and adaptive limitations, individuals with a developmental disability are less likely to have developed appropriate coping skills for a variety of their difficulties.3 (Note: a secondary condition is a disorder to which a person is more susceptible by virtue of having a primary disabling ailment.) 

"Over the past decades the prevalence of comorbid mental and physical disease increased dramatically, reaching epidemic proportions in many countries. In persons over the age of sixty the simultaneous presence of two or more diseases has become the rule rather than an exception. Comorbidity is also increasing rapidly at younger ages where the negative consequences of comorbid conditions are as numerous and as troublesome as those that occur at a higher age." 4 

There is every reason to believe that this increasing trend in the proportion of individuals who have comorbid conditions will continue in the years to come. The epidemic spread of unhealthy lifestyles increases the likelihood of occurrence of several diseases which tend to appear together, such as cardiovascular disease and diabetes. In addition, it is possible that deterioration of the environment will lead to a higher intake of pollutants and abnormalities in the immunological system of humans and thus, facilitate the occurrence of allergic and other diseases. 4

Comorbidity does not mean the simple addition of two diseases that independently follow their usual courses. The simultaneous presence of two or more diseases will worsen the prognosis of all the diseases that are present, lead to an increasing number (and severity) of complications, and make the treatment of all of them more difficult and, possibly, less effective. A series of reviews published in recent years provides ample confirmation of these findings. 4

What is worse is that one of the comorbid diseases often is overlooked. This is particularly true for mental illnesses which are frequently comorbid with physical illnesses. Non-psychiatric specialists and general practitioners specialists and general practitioners usually are focused on the illness about which they know a great deal and which they wish to treat, often missing or underestimating the importance of mental disorders that might also be present. Specialists in disciplines other than psychiatry and general practitioners avoid making a diagnosis of mental illness, because:

Psychiatrists are no better than other specialists at identifying comorbid conditions. They often deal with the mental illness they have extensive experience with and miss or under-treat comorbid physical illness and orthopedic problems. One can hope that in the future, all psychiatrists will acquire sufficient knowledge to diagnose and treat (or refer) non-psychiatric diseases and that the discipline of psychiatry will, therefore, become unnecessary. But we are far from this goal. For the time being we can admire psychiatrists who are able to provide care to people who have a physical as well as a mental disorder and regret that many cannot or do not wish to do so. 4

The reality is that in cases of comorbidity there is a direct association between the severity of the physical condition and most classes of mental disorders, as well as with functional impairment in youngsters. Specific patterns of comorbidity have important implications for determining the causes and mechanism for prevention and interventions of these conditions. 5

SPECIFIC EXAMPLES

2. Genetic disorders "The burden of genetic disorders associated with physical disabilities and psychiatric disorders is connected to increasing healthcare expenses and demands on the patients and their caregivers. Psychiatric comorbidities such as anxiety and mood disorders affect a large number of children and adolescents with genetic disorders, leading to poor quality of life and impaired psychological adjustment. Research on this population is scarce compared with studies on the comorbidity of psychiatric problems with physical illnesses (e.g. endocrine disorders and neurological problems)."7

Cerebral Palsy Cerebral palsy results from brain damage or injury; comorbidity frequently with reported conditions which provide further obstacles regarding self-care, independent living and symptom management. Risk factors may be reduced with proper medical attention and practical treatment plans as some conditions result from unattended disorder symptoms. 8

OVERVIEW

The lesson to be learned is that no extended group of children with disabilities should be defined by a single umbrella categorization (as with all children and adults). We can only improve our efforts to care for our children with an increased awareness of their individuality. •

ABOUT THE AUTHORS:

H. Barry Waldman, DDS, MPH, PhD is a SUNY Distinguished Teaching Professor, Department of General Dentistry, Stony Brook University, NY. E-mail: h.waldman@stonybrook.edu Rick Rader, MD, DHL (Hon) is the Director of Morton J. Kent Habilitation Center, Orange Groove, Chattanooga, TN, Senior VP Public Policy, American Academy of Developmental Medicine and Dentistry; Adjunct Professor, Human Development, University of Tennessee-Chattanooga. He is Exceptional Parent Magazine's Editor in Chief. Steven P. Perlman, DDS, MScD, DHL (Hon) is the Global Clinical Director and founder, Special Olympics, Special Smiles and Clinical Professor of Pediatric Dentistry, The Boston University Goldman School of Dental Medicine.

References

AMERICAN ACADEMY OF DEVELOPMENTAL MEDICINE AND DENTISTRY

The American Academy of Developmental Medicine and Dentistry (AADMD) was organized in 2002 to provide a forum for healthcare professionals who provide clinical care to people with neurodevelopmental disorders and intellectual disabilities (ND/ID). The mission of the organization is to improve the quality and assure the parity of healthcare for individuals with neurodevelopmental disorders and intellectual disabilities throughout the lifespan.