Attention-Deficit/Hyperactivity Disorder in Children and Adolescents E-Book

Brian P Daly

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Serie: Advances in Psychotherapy - Evidence-Based Practice
• Sprache: Englisch
• Veröffentlichungsjahr: 2023

Seitenzahl: 226

Beschreibung

State-of-the-art guidance on the effective assessment and treatment of children and adolescents with ADHD New updated edition Provides guidance on multimodal care and diversity issues Includes downloadable handouts This updated new edition of this popular text integrates the latest research and practices to give practitioners concise and readable guidance on the assessment and effective treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD). This common childhood condition can have serious consequences for academic, emotional, social, and occupational functioning. When properly identified and diagnosed, however, there are many interventions that have established benefits. This volume is both a compact "how to" reference, for use by professionals in their daily work, and an ideal educational reference for students. It has a similar structure to other books in the Advances in Psychotherapy series, and informs the reader of all aspects involved in the assessment and management of ADHD. Practitioners will particularly appreciate new information on the best approaches to the ideal sequencing of treatments in multimodal care, and the important diversity considerations. Suggestions for further reading, support groups, and educational organizations are also provided. A companion volume Attention-Deficit/Hyperactivity Disorder (ADHD) in Adults is also available.

Leseprobe

Advances in Psychotherapy – Evidence-Based Practice, Volume 33

Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

2nd edition

Brian P. Daly

Department of Psychological and Brain Sciences, Drexel University, Philadelphia, PA

Aimee K. Hildenbrand

Center for Healthcare Delivery Science, Nemours Children’s Health, Wilmington, DE

Shannon G. Litke

Department of Psychological and Brain Sciences, Drexel University, Philadelphia, PA

Ronald T. Brown

School of Integrated Health Sciences, University of Nevada, Las Vegas, NV

About the Authors

Brian P. Daly, PhD, is associate professor and department head of psychological and brain sciences at Drexel University. Dr. Daly is past president of the Philadelphia Behavior Therapy Association and recipient of grant funding from the Pew Charitable Trusts, W. K. Kellogg Foundation, Sixers Youth Foundation, Shire Pharmaceuticals, and Justice Resource Institute. He currently serves on the editorial board of Professional Psychology: Research and Practice, as well as on the advisory committees for several nonprofit organizations.

Aimee K. Hildenbrand, PhD, is an assistant professor of pediatrics at Sidney Kimmel Medical College of Thomas Jefferson University, an assistant research scientist at Nemours Children’s Health, and a pediatric psychologist at Nemours Children’s Hospital Delaware. Dr. Hildenbrand’s research program aims to improve delivery of pediatric health care to optimize pain management and psychosocial outcomes for youth with chronic illness, with a particular focus on pediatric sickle cell disease and cancer.

Shannon G. Litke, BA, is a doctoral student in the clinical psychology program at Drexel University working under the mentorship of Dr. Brian Daly. Ms. Litke’s interests include mechanisms of psychosocial treatment for child and adolescent trauma and anxiety disorders. She is particularly interested in improving interventions for at-risk youth from underserved communities.

Ronald T. Brown, PhD, ABPP, is the Dean of the School of Integrated Health Sciences at the University of Nevada, Las Vegas. Dr. Brown has been the past president of the University of North Texas at Dallas and also is the past president of the Association of Psychologists in Academic Health Centers and the Society of Pediatric Psychology of the American Psychological Association. Dr. Bown has published over 300 articles and chapters as well as 12 books related to childhood psychopathology and pediatric psychology.

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, Professor Emeritus, University of Missouri–Saint Louis, MO

Associate Editors

Jonathan S. Comer, PhD, Professor of Psychology and Psychiatry, Director of Mental Health Interventions and Technology (MINT) Program, Center for Children and Families, Florida International University, Miami, FL

J. Kim Penberthy, PhD, ABPP, Professor of Psychiatry & Neurobehavioral Sciences, University of Virginia, Charlottesville, VA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Continuing Education Credits

Psychologists and other healthcare providers may earn five continuing education credits for reading the books in the Advances in Psychotherapy series and taking a multiple-choice exam. This continuing education program is a partnership of Hogrefe Publishing and the National Register of Health Service Psychologists. Details are available at https://www.hogrefe.com/us/cenatreg

The National Register of Health Service Psychologists is approved by the American Psychological Association to sponsor continuing education for psychologists. The National Register maintains responsibility for this program and its content.

Library of Congress of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2023948954

Library and Archives Canada Cataloguing in Publication

Title: Attention-deficit/hyperactivity disorder in children and adolescents / Brian P. Daly,

Department of Psychology, Drexel University, Philadelphia, PA, Aimee K. Hildenbrand, Center for

Healthcare Delivery Science, Nemours Children’s Health, Wilmington, DE, Shannon G. Litke,

Department of Psychology, Drexel University, Philadelphia, PA, Ronald T. Brown, School of

Integrated Health Sciences, University of Nevada, LA.

Names: Daly, Brian P., author. | Hildenbrand, Aimee K., 1989- author. | Litke, Shannon G., author.

| Brown, Ronald T., author.

Series: Advances in psychotherapy--evidence-based practice ; v. 33.

Description: 2nd edition. | Series statement: Advances in psychotherapy--evidence-based practice ;

volume 33 | Includes bibliographical references.

Identifiers: Canadiana (print) 20230558240 | Canadiana (ebook) 20230558267 | ISBN 9780889376007

(softcover) | ISBN 9781613346006 (EPUB) | ISBN 9781616766009 (PDF)

Subjects: LCSH: Attention-deficit hyperactivity disorder. | LCSH: Attention-deficit hyperactivity

disorder—Diagnosis. | LCSH: Attention-deficit hyperactivity disorder—Treatment. | LCSH:

Attention-deficit disorder in adolescence. | LCSH: Attention-deficit disorder in adolescence—

Diagnosis. | LCSH: Attention-deficit disorder in adolescence—Treatment.

Classification: LCC RJ506.H9 D34 2023 | DDC 618.92/8589—dc23

© 2024 by Hogrefe Publishing

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Acknowledgments

Dr. Daly is grateful for Tina whose grace, character, and warmth are the definition of happiness. He thanks and loves the three joys of his life, Leo, Sofie-Mathilde, and Colt. He acknowledges the legacy of his parents, John M. and Mary F. Daly, who taught him the beauty of kindness and helping others.

Dr. Hildenbrand is grateful for her family, partner, mentors, colleagues, and the children and families who have allowed her to be a small part of their care and journey.

Mrs. Litke wishes to thank her mentor, Dr. Daly, her husband, Vipin, and all of her family and friends for their long-standing support and encouragement for pursuing her goals.

Dr. Brown wishes to thank Ryan for all of his support and love and missed soccer and baseball games over the years while his dad was overindulging in his research and writing.

Contents

1  Description

1.1  Terminology

1.2  Definition

1.3  Epidemiology

1.3.1  Prevalence and Incidence

1.3.2  Sex

1.3.3  Age

1.3.4  Culture

1.4  Course and Prognosis

1.5  Differential Diagnosis

1.5.1  Behavioral Conditions

1.5.2  Emotional Conditions

1.5.3  Neurologic or Developmental Conditions

1.5.4  Environmental and Psychosocial Factors

1.5.5  Physical and Medical Conditions

1.6  Comorbidity

1.6.1  ODD/CD

1.6.2  Anxiety

1.6.3  Mood

1.6.4  Bipolar Disorder

1.6.5  Learning Disorder

1.6.6  Tics/ASD

1.6.7  Substance Use Disorders

1.6.8  Sleep Issues

1.7  Diagnosis

1.7.1  Diagnostic Interviews

1.7.2  Rating Scales

1.7.3  Psychoeducational Testing

1.7.4  Neuropsychological Testing

1.7.5  Laboratory Testing

2  Theories and Models of ADHD in Children

2.1  Neurobiological Factors in ADHD

2.1.1  Genetic Contributions

2.1.2  Neurological Factors

2.1.3  Cognitive Determinants

2.2  Environmental Risk Factors

2.2.1  Pre-, Peri-, and Postnatal Factors

2.2.2  Environmental Toxins

2.2.3  Dietary Factors

2.3  Psychosocial Factors

2.4  Interactions Between Neurobiological, Environmental, and Psychosocial Factors

3  Diagnosis and Treatment Indications

3.1  Assessment Procedures

3.1.1  General Considerations

3.1.2  Developmental History

3.1.3  Clinical Interviews

3.1.4  Behavioral Rating Scales

3.1.5  Differential Diagnosis/Comorbidities

3.1.6  Testing

3.2  The Decision-Making Process

3.3  Treatment Considerations

4  Treatment

4.1  Methods of Treatment

4.1.1  Psychopharmacology

4.1.2  Stimulant Medications

4.1.3  Nonstimulant Medications

4.1.4  Psychosocial/Behavioral Therapies

4.1.5  Behavioral Parent Training

4.1.6  Behavioral Peer Interventions

4.1.7  Behavioral Classroom Management

4.1.8  Academic Interventions and Organizational Skills Training

4.1.9  School Accommodations

4.1.10  Neurofeedback and Cognitive Training

4.1.11  Psychoeducation

4.2  Mechanisms of Action

4.3  Efficacy and Prognosis

4.4  Variations and Combinations of Methods

4.5  Problems in Carrying Out the Treatment

4.6  Multicultural Issues

5  Case Vignettes

6  Further Reading

7  References

8  Appendix: Tools and Resources

|1|1Description

1.1  Terminology

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder marked by persistent patterns of inattention and/or hyperactivity-impulsivity symptoms that emerge during childhood and are functionally impairing across settings. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) assigns the following diagnostic codes for this disorder:

314.01 Attention-Deficit/Hyperactivity Disorder, Combined Presentation

314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation

314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive/Impulsive Presentation

314.01 Other Specified Attention-Deficit/Hyperactivity Disorder

314.01 Unspecified Attention-Deficit/Hyperactivity Disorder

The International Classification of Diseases (10th rev., Clinical Modification; ICD-10-CM; World Health Organization, 2021) lists ADHD under the following codes:

F90.0 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type

F90.1 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive Type

F90.2 Attention-Deficit/Hyperactivity Disorder, Combined Type

F90.8 Attention-Deficit/Hyperactivity Disorder, Other Type

F90.9 Attention-Deficit/Hyperactivity Disorder, Unspecified Type

First described within the medical literature in the late 1700s (Barkley & Peters, 2012), ADHD-related symptoms were previously referred to by numerous labels including “minimal brain damage,” “minimal brain dysfunction,” “hyperkinetic impulse disorder,” “hyperactive child syndrome,” “hyperkinetic reaction of childhood,” and “attention deficit disorder,” among others (Taylor, 2011). Changes in terminology generally reflected evolving theoretical conceptualizations based on symptoms of the disorder and its management.

|2|1.2  Definition

According to the DSM-5-TR, ADHD is “a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development” as defined by the diagnostic criteria listed in Box 1.

Box 1: DSM-5-TR Diagnostic Criteria for ADHD

A. Either 1 and/or 2:

Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (ages 17 and older), at least five symptoms are required.

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily distracted or sidetracked).

Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, cell phones).

Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (ages 17 and older), at least five symptoms are required.

Often fidgets with or taps hands or feet or squirms in seat.

Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

|3|Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless).

Often unable to play or engage in leisure activities quietly.

Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

Often talks excessively.

Often blurts out an answer before a question has been completed (e.g., completes people’s sentences, cannot wait for his or her turn in conversations).

Often has difficulty waiting his or her turn (e.g., while waiting in line).

Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing

B.  Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

C.  Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

D.  There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

E.  The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Specify whether:

314.01(F90.2) Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months.

314.00(F90.0) Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months.

314.01(F90.1) Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months.

Specify if:

In partial remission: When full criteria were previously met, fewer than the full criteria have been met for the past 6 months, and the symptoms still result in impairment in social, academic, or occupational functioning.

Specify current severity:

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.

Moderate: Symptoms or functional impairment between “mild” and “severe” are present.

Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning.

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text. rev.), https://doi.org/10.1176/appi.books.9780890425787 (Copyright © 2022). American Psychiatric Association. All Rights Reserved.

|4|According to ICD-10-CM (World Health Organization, 2019), the diagnostic criteria for ADHD are specified as follows:

Box 2: ICD-10-CM Diagnostic Criteria for ADHD

F90. Hyperkinetic Disorders: A group of disorders characterized by an early onset (usually in the first five years of life), lack of persistence in activities that require cognitive involvement, and a tendency to move from one activity to another without completing any one, together with disorganized, ill-regulated, and excessive activity. Several other abnormalities may be associated. Hyperkinetic children are often reckless and impulsive, prone to accidents, and find themselves in disciplinary trouble because of unthinking breaches of rules rather than deliberate defiance. Their relationships with adults are often socially disinhibited, with a lack of normal caution and reserve. They are unpopular with other children and may become isolated. Impairment of cognitive functions is common, and specific delays in motor and language development are disproportionately frequent. Secondary complications include dissocial behavior and low self-esteem.

Excludes:

Anxiety disorders

Mood [affective] disorders

Pervasive developmental disorders

Schizophrenia

F90.0 Disturbance of activity and attention:

Attention deficit:

Disorder with hyperactivity

Hyperactivity disorder

Syndrome with hyperactivity

Excludes:

Hyperkinetic disorder associated with conduct disorder

Reprinted with permission from the ICD-10-CM Classification of Mental and Behavioral Disorders, https://icd.who.int/browse10/2019/en#/F90 (Copyright © 2019). World Health Organization. All Rights Reserved.

1.3  Epidemiology

1.3.1  Prevalence and Incidence

Among the most frequently diagnosed mental health disorders, ADHD is estimated to affect about 7% of children and adolescents worldwide (Thomas et al., 2015). Although there has been concern that rates of ADHD have increased over time, evidence suggests no significant increase in prevalence when standardized diagnostic procedures are used (Polanczyk et al., 2014; Thomas et al., 2015). Rather, variability in prevalence estimates over the past three decades is driven primarily by heterogeneous study methodologies (e.g., sampling techniques, informants) and settings. Fewer studies have |5|examined the incidence of ADHD. Findings from a recent investigation by Shi et al. (2021) suggested that the cumulative incidence of ADHD is approximately 6.62–13.12% among school-age children in the US, whereas studies in the United Kingdom and Denmark indicate an incidence of approximately 59.7 to 91.2 per 100,000 in 2010 (Holden et al., 2013; Mohr Jensen & Steinhausen, 2015).

1.3.2  Sex

ADHD is diagnosed more frequently in males than in females, with an estimated ratio of 2:1 or higher (Sayal et al., 2018). However, this sex difference may be a result of older diagnostic criteria that were developed with predominantly male samples. Additionally, girls are more likely to present with primarily inattentive features and less likely to exhibit overt overactivity or comorbid conduct problems as compared to their male counterparts, which may account for markedly higher treatment referral rates among boys. Perhaps due to more careful identification of specific subtypes (predominantly inattentive presentation), the male to female ratio has reduced over the past two decades (Sayal et al., 2018). While ADHD is more common among boys, research suggests that both groups experience significant functional impairments in academic performance, comorbidity with learning disorders, and social problems (Hinshaw et al., 2012).

1.3.3  Age

ADHD typically emerges early in childhood and is most commonly identified during the elementary school years, when symptoms become more evident and impairing, particularly in academic settings. In preschool-aged children, this disorder primarily manifests as excessive motor activity. While ADHD may be diagnosed in very young children, as suggested in the DSM-5, symptoms of overactivity and hyperactivity are particularly difficult to differentiate from normative behaviors for children below the age of 4 years (American Psychiatric Association, 2013). Inattention appears to become more prominent during elementary school. During adolescence, hyperactivity symptoms tend to shift from overt motoric signs (e.g., running, climbing) to more subtle symptoms including fidgetiness, restlessness, or impatience. A substantial proportion of children with ADHD continue to exhibit symptoms into adulthood that result in impairments across settings and situations.

1.3.4  Culture

There is little doubt that ADHD occurs across all nationalities and cultures. Indeed, a consistent two-factor ADHD symptom structure has been replicated across cultures for school-age children (Bauermeister et al., 2010). |6|However, prevalence rates, as well as diagnostic and management practices, vary within and across countries. Thomas and colleagues (2015) found that prevalence estimates were, on average, 4% higher in the Middle East relative to the US. After adjusting for DSM edition and measurement, ADHD prevalence rates were on average 2% higher in the US relative to Europe. With regards to prescribing patterns for medications for ADHD, evidence suggests that methylphenidate is the leading pharmacotherapy across several European countries, whereas in the US the use of amphetamines and methylphenidate is comparable (Bachmann et al., 2017).

1.4  Course and Prognosis

The onset of ADHD symptoms typically occurs during early childhood. From childhood to adolescence, inattention tends to remain stable or become more prominent, whereas hyperactivity typically shifts from impulsive, disinhibited behavior to feelings of restlessness or impatience. However, recent work indicates significant variation among individuals with regard to the developmental course of ADHD symptoms, driven by genetic and environmental factors distinct from those influencing baseline symptoms (Pingault et al., 2015; Pingault et al., 2011). A considerable proportion of youth with ADHD continues to meet criteria for this disorder into adolescence (i.e., approximately 50–80%) as well as into adulthood (35–65%; American Psychiatric Association, 2013), with ADHD severity and comorbid conduct disorder (CD) and major depressive disorder predicting persistence from childhood into adulthood (Caye et al., 2016). Approximately 10–20% of children with ADHD will not demonstrate any symptoms or impairment as adults suggesting that relatively few people appear to fully “outgrow” ADHD in adulthood.

If left untreated, ADHD can result in significant impairments across the life span. Specifically, relative to youth without the disorder, those with ADHD are at increased risk for poorer academic and social functioning, unintentional injuries and motor vehicle accidents, poor self-esteem, substance use (particularly those with comorbid oppositional defiant or conduct disorder), and compromised occupational outcomes (Arnold et al., 2020; Harpin et al., 2016). As such, appropriate treatment should be initiated as early as possible, address multiple domains of functioning, and be continuously evaluated over time (see Chapter 4 for further discussion of treatment). Systematic reviews suggest that treatment improves long-term outcomes compared with untreated ADHD (Shaw et al., 2012), with the greatest benefits observed for academic outcomes, self-esteem, and social functioning (Arnold et al., 2015).

|7|1.5  Differential Diagnosis

ADHD is a clinically heterogeneous disorder in which youth exhibit signs and symptoms that are also present in other psychiatric and/or medical conditions. This can make differential diagnosis challenging even for the experienced practitioner (see Table 1). For instance, the DSM-5 lists 16 conditions or groups of conditions to be distinguished from ADHD. Estimates indicate that generally one third to two thirds of all youth with ADHD also have a second condition (Danielson et al., 2018), highlighting the importance of screening for comorbid conditions. The categories in which symptomatic overlap most frequently occur include emotional regulation disorder (e.g., anxiety, depression) or disruptive behavior conditions (e.g., oppositional defiant, intermittent explosive, and CDs), neurologic or developmental disorders (e.g., learning and language disorders, fine and gross motor difficulties, executive function challenges, or other neurodevelopmental disorders), physical or medical conditions (e.g., tics, lead poisoning, sleep apnea), and psychosocial or environmental factors (e.g., stressful home environment, trauma, parental psychopathology, ineffective schooling). Because these conditions may mimic symptoms or be comorbid with ADHD, the clinician should consider alternative explanations and, if appropriate, diagnose each condition independently because each diagnosis may require a specific mode of treatment.

In the case of a comorbid condition, the clinician should determine which of the coexisting conditions is primary or secondary (e.g., disorders that are exacerbated by the ADHD) as this will likely influence treatment decisions. For example, an 8-year-old boy who consistently struggles with focusing and inattention at school may develop problems with anxiety due to school performance and self-esteem issues. It also is important to recognize that ADHD presentations and associated common comorbidities change over time and developmental stages. For example, oppositional defiant disorder (ODD), enuresis, and language disorders are more common during the early childhood years. During the school-age years, anxiety, specific learning disorders (SLD), and tics are most prevalent. Early and late adolescence is associated with the emergence of internalizing disorders (e.g., depression, anxiety) and substance use disorders (SUD). Finally, clinicians should consider how cultural factors impact the stigma of having a psychological disorder, influence symptom presentation, and how familial and societal cultural factors may affect management of ADHD.

|8|Table 1  Overlapping Symptoms Between ADHD and Other Psychiatric Disorders

ADHD

ODD

Conduct disorder

Depression

Anxiety

OCD

Adjustment disorder

Bipolar disorder

PTSD

Substance use/abuse

Inattention symptoms

Fails to give close attention to details or makes careless mistakes in schoolwork

✓

✓

Trouble holding attention on tasks or play activities

✓

✓

✓

✓

✓

✓

Does not seem to listen when spoken to directly

✓

Does not follow through on instructions and fails to finish schoolwork or chores

✓

✓

✓

Trouble organizing tasks and activities

✓

Loses things necessary for tasks and activities

✓

Easily distracted

✓

✓

Forgetful in daily activities

✓

✓

Hyperactivity and impulsivity symptoms

Fidgets with or taps hands or feet, or squirms in seat

✓

✓

Leaves seat in situations when remaining seated is expected

|9|Runs about or climbs in situations where it is not appropriate

✓

✓