adhd case study child

ADHD Case Study: Unveiling Real-Life Experiences and Treatment Approaches

Brace yourself for a journey through the kaleidoscopic world of ADHD, where case studies illuminate the vibrant, chaotic, and often misunderstood experiences of those living with this complex condition. Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that affects millions of individuals worldwide, impacting their daily lives in profound and diverse ways. As we delve into the realm of ADHD case studies, we’ll uncover the intricate tapestry of symptoms, challenges, and triumphs that define the ADHD experience.

ADHD is characterized by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with functioning and development. According to the Centers for Disease Control and Prevention (CDC), approximately 9.4% of children aged 2-17 years in the United States have been diagnosed with ADHD, with the prevalence in adults estimated to be around 4.4%. These statistics underscore the significant impact of ADHD on individuals, families, and society as a whole.

The value of case studies in understanding ADHD cannot be overstated. While statistical data and clinical definitions provide a framework for comprehending the disorder, it is through the lens of individual experiences that we truly grasp the nuanced reality of living with ADHD. Case studies offer a window into the personal struggles, adaptive strategies, and unique strengths of those navigating life with this condition. By examining these real-life narratives, we gain invaluable insights that inform treatment approaches, support systems, and ADHD research .

Understanding ADHD Through Case Studies

Case studies in ADHD research come in various forms, each offering a distinct perspective on the disorder. Some focus on longitudinal observations, tracking an individual’s journey from childhood through adulthood. Others provide snapshots of specific challenges or interventions at particular life stages. There are also comparative case studies that examine ADHD presentations across different demographics or in conjunction with comorbid conditions.

The benefits of analyzing real-life ADHD cases are manifold. Firstly, they humanize the disorder, moving beyond clinical descriptions to reveal the day-to-day realities of living with ADHD. This personal touch fosters empathy and understanding among healthcare providers, educators, and the general public. Secondly, case studies often uncover unique coping mechanisms and strategies developed by individuals with ADHD, which can inform and inspire others facing similar challenges.

Moreover, case studies contribute significantly to ADHD research and treatment by highlighting patterns, raising new questions, and sometimes challenging existing assumptions. They provide a rich source of qualitative data that complements quantitative research, offering a more holistic understanding of the disorder. This comprehensive approach is crucial in developing effective, personalized treatment plans and support systems for individuals with ADHD.

Case Study on ADHD: The Story of Sarah

To illustrate the power of case studies, let’s delve into the story of Sarah, a 28-year-old marketing professional whose journey with ADHD spans from childhood to her current career.

Background and Early Signs: Sarah’s parents first noticed her restlessness and difficulty focusing during preschool. She was constantly in motion, struggled to complete tasks, and often seemed to be “in her own world.” Despite being bright and creative, Sarah’s academic performance was inconsistent, and she frequently lost or forgot important items.

Challenges in School and Social Settings: As Sarah progressed through elementary and middle school, her ADHD symptoms became more pronounced. She struggled to organize her thoughts and materials, often turning in assignments late or incomplete. Socially, Sarah’s impulsivity and tendency to interrupt others made it difficult for her to maintain friendships. Her self-esteem suffered as she internalized the frustration of teachers and peers who misinterpreted her behavior as laziness or disrespect.

Diagnosis Process and Initial Treatment: At age 12, Sarah’s parents sought professional help. After a comprehensive evaluation involving interviews, behavioral assessments, and cognitive tests, Sarah was diagnosed with ADHD, predominantly inattentive type. The diagnosis was both a relief and a challenge for Sarah and her family. They embarked on a journey to understand the disorder and explore treatment options.

Initially, Sarah’s treatment plan included a combination of stimulant medication and behavioral therapy. The medication helped improve her focus and impulse control, while therapy sessions taught her strategies for organization, time management, and social skills. Sarah’s parents and teachers also received education on ADHD, enabling them to create a more supportive environment.

Long-term Management and Outcomes: As Sarah entered adulthood, she continued to refine her ADHD management strategies. She learned to leverage her creative strengths in her marketing career while implementing systems to compensate for her organizational challenges. Sarah’s journey exemplifies the ongoing nature of ADHD management and the potential for individuals with ADHD to lead fulfilling, successful lives.

ADHD Case Study Examples: Diverse Presentations

Sarah’s story is just one example of the myriad ways ADHD can manifest. Let’s explore three more case studies that highlight the diversity of ADHD presentations and the importance of tailored interventions.

Case 1: Adult ADHD in the Workplace John, a 35-year-old software engineer, was diagnosed with ADHD in his late twenties. Despite his technical brilliance, John struggled with project deadlines, time management, and interpersonal communication at work. His case study reveals the unique challenges of adult ADHD in professional settings and the effectiveness of workplace accommodations, such as flexible schedules and task management tools. John’s experience underscores the importance of mastering life with ADHD in professional contexts.

Case 2: ADHD in a Gifted Child Emma, a 9-year-old identified as intellectually gifted, exhibited classic ADHD symptoms that were initially masked by her high academic achievement. Her case study highlights the complexities of diagnosing and supporting twice-exceptional children. Emma’s journey emphasizes the need for nuanced approaches to ADHD and learning , balancing intellectual stimulation with strategies to address executive function deficits.

Case 3: ADHD with Comorbid Anxiety Disorder Michael, a 19-year-old college student, grapples with both ADHD and generalized anxiety disorder. His case study illustrates the challenges of managing co-occurring conditions and the importance of integrated treatment approaches. Michael’s experience sheds light on the interplay between ADHD symptoms and anxiety, informing strategies for addressing complex presentations of the disorder.

Comparing and contrasting these diverse ADHD presentations reveals the heterogeneity of the disorder and the necessity for individualized assessment and treatment plans. Each case offers unique insights into the varied manifestations of ADHD across different life stages, cognitive profiles, and comorbid conditions.

Analyzing Treatment Approaches in ADHD Case Studies

The case studies we’ve explored demonstrate the range of treatment approaches used in managing ADHD. Let’s examine these interventions in more detail:

Medication-based Interventions: Pharmacological treatments, particularly stimulant medications like methylphenidate and amphetamines, play a significant role in many ADHD management plans. Sarah’s case illustrates how medication can improve core symptoms of inattention and hyperactivity. However, as seen in Michael’s situation with comorbid anxiety, medication selection and dosing require careful consideration of individual factors and potential side effects.

Behavioral Therapy and Cognitive Strategies: Cognitive-behavioral therapy (CBT) and other psychosocial interventions are crucial components of comprehensive ADHD treatment. These approaches help individuals develop coping strategies, improve executive functioning, and address emotional regulation. In Emma’s case, cognitive strategies were particularly important in helping her harness her intellectual strengths while managing ADHD symptoms.

Educational Accommodations and Support: For children and adolescents with ADHD, school-based interventions are often essential. These may include individualized education plans (IEPs), classroom accommodations, and specialized tutoring. Emma’s case highlights the importance of tailoring educational approaches to meet the unique needs of gifted children with ADHD.

Holistic Approaches: Diet, Exercise, and Lifestyle Changes: Many case studies, including John’s, emphasize the role of lifestyle factors in ADHD management. Regular exercise, balanced nutrition, adequate sleep, and mindfulness practices can significantly impact ADHD symptoms and overall well-being. These holistic approaches often complement traditional treatments and empower individuals to take an active role in managing their condition.

The effectiveness of these treatment approaches varies among individuals, underscoring the importance of personalized care plans. ADHD clinical trials continue to explore new interventions and refine existing ones, contributing to the evolving landscape of ADHD treatment options.

Lessons Learned from ADHD Case Studies

The wealth of information gleaned from ADHD case studies offers valuable insights for healthcare professionals, educators, and individuals affected by the disorder:

Key Insights for Healthcare Professionals: Case studies underscore the importance of comprehensive assessment and individualized treatment planning. They highlight the need for ongoing monitoring and adjustment of interventions, as ADHD presentations can evolve over time. Healthcare providers are reminded of the significance of considering comorbid conditions and life circumstances when developing treatment strategies.

Implications for Educators and Parents: The diverse presentations of ADHD illustrated in case studies emphasize the need for flexible and supportive educational environments. Educators and parents can learn from these narratives to better understand the challenges faced by individuals with ADHD and implement effective support strategies. The success stories within these case studies also serve as powerful motivators, showcasing the potential for individuals with ADHD to thrive with appropriate support.

Importance of Personalized Treatment Plans: Perhaps the most crucial lesson from ADHD case studies is the necessity of tailored interventions. What works for one individual may not be effective for another, highlighting the need for a patient-centered approach to ADHD management. This personalization extends beyond medication to encompass behavioral strategies, environmental modifications, and lifestyle adjustments.

Future Directions in ADHD Research: Case studies often uncover areas requiring further investigation, driving new research questions and methodologies. They can reveal emerging trends, such as the increasing recognition of adult ADHD, and inform the development of novel treatment approaches. The rich, qualitative data provided by case studies complement quantitative research, offering a more nuanced understanding of ADHD’s impact on daily life.

As we conclude our exploration of ADHD case studies, we’re reminded of the profound value these narratives bring to our understanding of the disorder. They offer a vivid portrayal of the challenges, triumphs, and everyday realities of living with ADHD, moving beyond clinical definitions to capture the human experience of the condition.

The case studies we’ve examined underscore the critical importance of individualized approaches to ADHD management. From Sarah’s journey through childhood and into a successful career, to John’s workplace adaptations, Emma’s twice-exceptional experience, and Michael’s complex presentation with comorbid anxiety, each story highlights the unique constellation of symptoms, strengths, and needs that characterize ADHD.

These personal accounts serve as powerful tools for raising awareness and fostering empathy. They challenge stereotypes and misconceptions about ADHD, revealing the diverse ways in which the disorder manifests across different individuals and life stages. Moreover, they offer hope and inspiration, showcasing the potential for individuals with ADHD to lead fulfilling, successful lives with appropriate support and interventions.

As we move forward, it’s crucial to continue sharing and learning from ADHD stories . These narratives not only inform clinical practice and research but also empower individuals with ADHD and their support networks. They remind us that behind every diagnosis is a unique individual with their own story, challenges, and potential.

Let us carry forward the insights gained from these case studies to create more inclusive, understanding, and supportive environments for individuals with ADHD. By doing so, we can contribute to a world where ADHD is not seen as a limitation, but as a different way of experiencing and interacting with the world—one that comes with its own set of challenges and remarkable strengths.

As we continue to unravel the complexities of ADHD through research, clinical practice, and personal narratives, let us remain committed to supporting, empowering, and celebrating the diverse experiences of individuals living with this fascinating and challenging condition. After all, it is through understanding and embracing these differences that we can truly appreciate the rich tapestry of human neurodiversity.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Barkley, R. A. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). New York: Guilford Press.

3. Faraone, S. V., Biederman, J., & Mick, E. (2006). The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychological Medicine, 36(2), 159-165.

4. Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., … & Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. American Journal of Psychiatry, 163(4), 716-723.

5. National Institute for Health and Care Excellence. (2018). Attention deficit hyperactivity disorder: diagnosis and management. NICE guideline [NG87]. https://www.nice.org.uk/guidance/ng87

6. Sibley, M. H., Swanson, J. M., Arnold, L. E., Hechtman, L. T., Owens, E. B., Stehli, A., … & Jensen, P. S. (2017). Defining ADHD symptom persistence in adulthood: optimizing sensitivity and specificity. Journal of Child Psychology and Psychiatry, 58(6), 655-662.

7. Thapar, A., Cooper, M., & Rutter, M. (2017). Neurodevelopmental disorders. The Lancet Psychiatry, 4(4), 339-346.

8. Wilens, T. E., & Spencer, T. J. (2010). Understanding attention-deficit/hyperactivity disorder from childhood to adulthood. Postgraduate Medicine, 122(5), 97-109.

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Childhood ADHD – Luke’s story

In the final part of her ADHD series, Dr Sabina Dosani, Child and Adolescent Psychiatrist and Clinical Partner London, introduces Luke, a patient she was able to help with his ADHD.

ADHD is one of the most common diagnoses for children in the UK and it is thought that 1 in 10 children will display some signs. For some children, their ADHD is severe and can have a huge impact on their ability to engage in school and to build and sustain relationships. Left untreated, evidence shows that those with ADHD are more likely to get into car accidents, engage in criminal activity and may struggle to keep a job or maintain relationships.

Luke, aged six, gets into trouble a lot at school. His mother gets called by his teacher three or four times a week for incidents of fighting, kicking and running in corridors. He is unable to finish his work and becomes quickly distracted. At home, he seems unable to sit still for any length of time, has had several falls when climbing trees and needs endless prompts to tidy his toys.

At school, he annoys his classmates by his constant interruptions, however if he has one-to-one attention from a student teacher who happens to be in his class on a placement he is able to settle and finish the work set. His father was said to have been a ‘lively’ child, then a ‘bright underachiever’ who occasionally fell foul of the law.

The school thought a visit to the GP might be a good idea. At the GP surgery, Luke ran and jumped about making animal noises. He swung on the back legs of a chair and took the batteries out of an ophthalmoscope. He was referred to a me for an assessment.

After a careful assessment, which included collecting information from school, questionnaires and observations of Luke, a diagnosis of ADHD was made. Following a discussion of the treatment options, the family decided they did not want any medication.

The first-line treatment for school‑age children and young people with severe ADHD and severe impairment is drug treatment. If the family doesn’t want to try a pharmaceutical, a psychological intervention alone is offered but drug treatment has more benefits and is superior to other treatments for children with severe ADHD.

 Luke's mother was asked to list the behaviours that most concern her. She was encouraged to accept others like making noises or climbing as part of Luke’s development as long as it is safe.

Now, when Luke fights, kicks others or takes risks like running into the road he is given “time-out” which isolates him for a short time and allows him and his parents or teacher to calm down. To reduce aggression and impulsivity, Luke is taught to respond verbally rather than physically and channel energy into activities such as sports or energetic percussion playing.

Over time, Luke’s parents have become skilled at picking their battles. Home is more harmonious. They fenced their garden, fitted a childproof gate and cut some branches off a tree preventing him climbing it. His parents are concerned about Luke’s use of bad language. They have been supported to allow verbal responses as a short-term interim. Whilst these might be unacceptable in other children they are preferable to physical aggression.

At school, Luke is less aggressive, has a statement of special educational need and now works well with a classroom assistant. He has been moved to the front of the class, where the teacher can keep a close eye on him, and given one task at a time. He is given special tasks, like taking the register to the school office, so he can leave class without being expected to sit still for long periods.

Through parental training, Luke’s parents have been able to help Luke work with his challenges to better manage them. As Luke grows and develops and as he faces new challenges in life, Luke may need to revisit the efficacy of ADHD medication. His parents now feel a lot more confident in being able to help Luke and he is a happier child and more settled.

Dr Sabina Dosani

Consultant Child & Adolescent Psychiatrist

Dr Sabina Dosani is a highly experienced Consultant Psychiatrist currently working for the Anna Freud Centre looking after Children and Adolescents. She has a Bachelor of Medicine and Bachelor of Surgery as well as being a member of the Royal College of Psychiatrists . Dr Dosani also has a certificate in Systemic Practice (Family Therapy).

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Pediatric Case Study: Child with ADHD

Nicole quint, dr.ot, otr/l.

• Early Intervention and School-Based

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Attention deficit hyperactivity disorder (adhd).

Hello everyone. Today, we are going to be talking about attention deficit hyperactivity disorder. I consider this to be under the umbrella of "invisible diagnoses." This population has a special place in my heart because it is very easy to misconstrue some of the challenges that they have as intentional and behavior-based, and therefore, sometimes they get a bad rap. Thus, I am always happy to help kids with ADHD.

Figure 1.  Overview of ADHD.

Individuals with ADHD have a lot of challenges that affect their occupational participation and performance. I think most of us are very comfortable with the idea that inattention, hyperactivity, and impulsivity are the hallmarks, but what sometimes can get lost is the idea that executive functions are very much affected by impulsivity. Motor issues are also often involved with kids with ADHD and are not always considered. In fact, there is a lot of evidence to support that the motor needs of these kids often go unaddressed. Typically, these kids come to us when parents or schools have major concerns about their behavior. Therefore, this tends to be where everyone focuses their attention. Oftentimes, the motor issues then fly under the radar and do not get addressed. The cool thing is that motor interventions can be the means to make some really significant changes for these kids, particularly in the area of executive function. There is a win-win situation when we address the motor issues. Lastly, they tend to also have performance issues not only in their home environment but also in their school and social environments as well.

Figure 2.  Other information from the NIMH Information Resource Center (2020).

I wanted to provide some information to help you to appreciate how diverse ADHD is. Many might still use ADD when we are talking about the children who have an inattentive type as it seems to make more sense. However, that is not how it is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5).

Etiology and Signs

The etiology and the signs are inattention, hyperactivity, and impulsivity. We also know there is a genetic predisposition to this. Neonatal exposure to cigarettes, alcohol, and drugs can also lead to ADHD. Low birth weight and toxin exposure are some of the environmental elements. ADHD can also be the result of a brain injury. This is not just a childhood disorder, and people do not grow out of it. In fact, the symptoms can actually get worse as life gets harder as one gets older. Adults who have ADHD can have some significant struggles, particularly if they do not know that they have ADHD or if it was never addressed.

There are three phenotypes: hyperactive-impulsive type, predominantly inattentive type, and a combination type. I think the hyperactive-impulsive type is the picture most people have when they think of ADHD. Then, we have the predominantly inattentive type. These are the daydreamers or the individuals that jump from one thought to the next. They have a really hard time staying focused for long. Lastly, there is the combined type. This is where we see both elements of inattention and hyperactivity and/or impulsivity. I think it is really important to also appreciate gender differences. You can see very different types of ADHD in girls versus boys. Boys obviously tend to be of the hyperactive-impulsive type, but even the inattentive type can be a little different. Girls, who have ADHD, tend to be talkative and a little more anxious. They definitely have a different predisposition as opposed to the boys. Thus, it might be the same diagnosis but look very different between the genders.

Functional Implications

Functional implications become extremely important. These are individuals who tend to overlook or miss details. They might make careless mistakes. They have difficulty following through with directions at school. Material management can become very challenging especially dealing with paperwork. They can miss deadlines and have a hard time keeping track of and prioritizing tasks. These are some of the higher-level executive functions. You might also see an avoidance or an expressed dislike of tasks that require a significant amount of sustained mental effort. They might tell you it is too hard, and they might feel very overwhelmed. They become very easily distracted by anything. The use of electronics adds to the issue. They can be forgetful in daily activities, talk excessively, have difficulty engaging in quiet activities, and tend to blurt out answers or finish others' sentences. Often, the perception is they are interrupting and being rude. They may have difficulty waiting for their turn or interrupt during someone else's turn. These are examples of impulsive behaviors. We will talk more about this when we get to executive functions. 

Differential Diagnosis Between ADHD and SPD

• A high rate of comorbidity between SMD and ADHD
• ADHD and SMD
• Both at risk for limited participation in many aspects of daily life
• ADHD slightly worse attention scores than SMD
• Tactile, taste/smell, and movement sensitivity, visual-auditory sensitivity; behavioral manifestations of sensory systems
• Exaggerated electrodermal responses to sensory stimulation, thus increased risk of sympathetic “fight or flight” reactions

(Miller et al., 2012; Yochman et al., 2013)

Sometimes, kids who have ADHD also have some sensory issues. You may wonder, "Do they have just ADHD by itself?" This is probably one of the most common questions I get when working with kids with ADHD whether it is from teachers, other therapists, or from parents. Next, we are going to be talking about a child who has straight ADHD. However, for a few minutes, I want to talk about the whole idea of differential diagnosis between ADHD and SPD and how this all fits together. There is a very high comorbidity between sensory modulation disorder and ADHD. When I am referring to sensory modulation disorder, I am using the Lucy Jane Miller nosology. Sensory modulation disorder refers to the over-responsive, under-responsive, and/or craving of sensory input. For both ADHD and sensory modulation disorder, you will see that these diagnoses are both at risk for limited participation. These are kids who will not participate in certain activities because the sensory input is too much or overwhelming for them. ADHD will have slightly worse attention scores than SMD when you complete a formal attention test like the Test of Everyday Attention. However, you will see the same kind of impulsive behaviors.

Those with sensory modulation disorders tend to have difficulty with tactile, taste, smell, and movement sensitivities. You might also see some visual-auditory sensitivity so there are some behavioral manifestations that come of that. They might become stressed related to fears of vestibular or other movement input. They might also dislike certain noises or touch.

They found in the research that sensory modulation dysfunction,  not ADHD , will have an exaggerated electrodermal response to sensory stimulation. This means that they have an increased risk of sympathetic activation which is the fight-or-flight, freeze/faint reactions, and meltdowns. When you have a child with meltdowns, you want to investigate if they have sensory modulation dysfunction right away. And, if you have a child with ADHD who does not have a history of meltdowns, that is a really good sign of your initial hypothesis. While this alone does not mean that they do not a sensory modulation dysfunction, chances are that they do not. Additionally, they might have dyspraxia or a discrimination disorder.

This is just a brief summary of how this all comes to play with an ADHD diagnosis and possible comorbidities.

Case Introduction: Jeremy (Age 9, ADHD, Combined Type) 

• He lives with his mother and older sister in SFH and goes to his father’s house on the weekend (divorced)
• He is in the 4th grade and has an IEP for OHI
• Strengths: funny, good at math, helps the family to take care of pets, watches WWE with father, loves dogs, likes to play board games (Monopoly, Sorry)
• School concerns: material management, organization,  completing tasks or losing work , impulsive, social difficulties (short-lived relationships, fights), “lacks self-control” and “messy”, underperforming and sometimes seems “lost”
• Family concerns: Fights with a sibling, sleep difficulties, messy room, messy notebooks, and backpack, loses things, avoids homework, resists bedtime,  difficult to wake in the morning and slow with routine , poor hygiene
• Jeremy’s goal: make friends, be able to find his schoolwork, have good friends, be better at kickball and wrestling

Jeremy is nine, and his diagnosis is ADHD, combined type. I have a feeling Jeremy is probably similar to a lot of the kids you see. I know I have seen a lot of these types of kids. He lives with his mother and older sister in a single-family home and goes to his father's house on the weekend because of a divorce. He is in the fourth grade, is eligible for an IEP because of an OHI (other health impairment), and is eligible for special education services because of his diagnosis of ADHD.

I always like to start with strengths with all kids, especially ADHD because these kids can have a really hard time with confidence and self-esteem. They also get blamed for their behaviors. For his strengths, he is funny, good at math, and he likes to help take care of his pets at home. He likes to watch wrestling, World Wrestling Federation (WWF) with his father, loves dogs, and loves to play board games. He is really good at Monopoly and Sorry.

At school, he had challenges with material management, organization, completing tasks, and not losing work. These last two are highlighted as we are going to focus on that. He is impulsive, and he has social difficulties. His teacher described his relationships as short-lived. He would have a friend, and then all of a sudden, they were not friends anymore. She also reported that he lacked self-control, was messy, and thought he underperformed. And, she felt like he always seemed lost. When they were going through the instructions or going through something, he was always looking at his peer's work or looking confused while he was trying to figure out what was going on.

The family had some concerns about his fighting with a sibling, significant sleep difficulties, a messy room, messy notebooks and backpack, and that he would often lose things. He also avoided his homework and resisted bedtime. As a result, it was very difficult to wake him up in the morning, and he was slow with his AM routine. His mom said that he also had an impulsive way of performing hygiene tasks. For example, he would brush his teeth in two seconds and say he was done. Everything was quick and impulsive. This is very typical for boys with this type of ADHD.

His goals were to make friends and find his school work. He said it was very stressful to always feel like he was losing his school work. He was motivated to do well in school. He did not just want to make friends, but he wanted to have good friends. He also wanted to be better at kickball because that is what the kids played at recess and in PE. He also wanted to be better at wrestling as not only did he like to watch with his dad, but he also liked to wrestle with him.

I want to go back to the highlighted areas in my list: completing tasks, losing work, and difficulty waking in the morning. These are the areas we are going to focus on.

Assessments

Assessments are one of the most challenging things for people because they are often under a time crunch, and the reports are difficult to write up and are time-consuming. However, it is really important with these kids as it gives us a full perspective on where they are having challenges. Knowing that he has "ADHD combined type" does not really tell us about his occupational performance and participation. We want to really get all that information. I like to be pretty thorough, and I will scatter assessments throughout my time with them to try to get a good idea. Again, I really like to check out their motor skills. I have kids that are superstars in sports, but I will still find out that there are some motor problems.

Typically, the motor challenges with ADHD have to do with bilateral coordination, dexterity, and those kinds of things. They might be good at some things, like basketball or baseball, but this does not mean that they are good at fine manipulation. Thus, it is really important to find out where they are. Figure 3 shows a summary of the assessments I did with Jeremy.

Figure 3.  Assessment results.

Using the BOT, I found that Jeremy was one standard deviation below the norm in fine motor, precision, and manual dexterity, which was not surprising. He was two standard deviations below the norm in bilateral coordination and balance. However, his overall strength, running speed, and agility were fine. 

There are many great tools out there for sleep including free ones. One of my favorites is the Sleep Habits Questionnaire. It is free online. It is great because it uncovers behaviors regarding going to bed, sleep duration, daytime sleepiness, and sleep onset delay. Many kids with ADHD have an overactive thinking process which then causes a sleep latency problem. It is hard for them to settle their brain and get to sleep. They also might have difficulty with sleep duration and not get enough sleep or good quality of sleep. If their arousal level is still high at night, it' is hard to get them to calm down and want to go to bed, especially if they are very disorganized in their thinking. This questionnaire gives you good information. Our results with Jeremy found that had bedtime resistance, sleep duration, daytime sleepiness, and sleep onset delays that were all atypical scores.

I also did a social skills assessment with him because his goal was to make friends, and school indicated that he had a hard time with solid friendships. I like to have a social-emotional learning perspective, and the more I know about a child's emotional intelligence, the better. We want these kids to be successful in their social interactions because that affects their whole life. With the Social Skills Improvement System (SSIS) Rating Scales, I found challenges with cooperation, empathy, and self-control. His strengths included assertion, responsibility, and communication. Under "problem behaviors", I found inattention, hyperactivity, and some externalizing behaviors. With his diagnosis, this all seems to fit. For academics, he was motivated to learn and had competence in math achievement. We already knew he had strengths in math.

I also did the School Function Assessment. I love this tool. There is one section that is a little dated as it talks about a floppy disk or something, but the other information on there is fantastic. This is especially true if you have kids who have a hard time following rules, social conventions, and material management. You can give it to the teacher, and they can score that. I found that Jeremy had some affected areas with memory and understanding, following social conventions, and compliance with adult directives and school rules. Additionally, he had some behavioral regulation issues, and task behavior and completion were difficult for him. His strengths included positive interactions and functional communication. Communication is strong for him,= which is a good thing.

The BRIEF (Behavior Rating Inventory of Executive Function) is an executive function tool that I did that with his parents. What we found was that the organization of materials, monitoring, planning and organization, inhibition, and initiation were difficult for him. His strengths were his working memory. Additionally, cognitive shifting and emotional control were also strong. However, his global executive composite was one standard deviation below the mean which means that he was low in everything. While it was not devastatingly low, he was below the average in everything. He struggled the most in metacognition, and that was two standard deviations below the norm. Thinking about his own thinking was a struggle for him.

From an observation standpoint, I also got a video from him mom of his AM routine so I could see what that looked like. He was in slow motion, very tired, not wanting to do the routine, and his performance was of low quality, I would put it, writing examples from school, because sometimes you'll see that the handwriting is indicative kind of the brain and the body not matching up, the brain going a little faster than the body. And so I also had a homework video watching him kind of resist homework. And then I did ocular motor testing, checked his tracking, convergence, divergence, and saccades and those kinds of things. Because there is a correlation between having some difficulties with that sometimes. But he actually was fine, and that wasn't a complaint from parents. So I just wanted to make sure it wasn't an issue that we were missing. So that gave me a lot of information.

Research Implications: Assessment

This is information about some of the research implications regarding the assessment process and kind of why I chose the tools that I chose and why I recommend a comprehensive one.

• Motor:  Children with parent-reported motor issues received more PT than those with teacher-reported motor issues (risk)/undertreated motor problems in children with ADHD (due to behavioral factors in referral); HW difficulties; higher ADHD and lower motor proficiency scores reported more sleep problems (Papadopoulos et al., 2018)
• Sleep:  Sleep deficits negatively affect inhibitory control (Cremone-Caira et al., 2019); Difficulties initiating and maintaining sleep 25-50% in ADHD (Corkum et al., 1998); Prevalence of sleep disorders 84.8 % affecting QoL (Yurumez & Gunay Kilic, 2013)
• EF:  Motor skills and EF related (Pan et al., 2015); boys with ADHD have lower EF abilities than typical peers on both performance-based and parent report tools, thus combo is recommended (Sgunibu et al., 2012)
• Social:  Children with ADHD 50% lower odds of sports participation than children with asthma with higher incidences of screen time (Tanden et al., 2019); childhood ADHD associated with obesity (Kim et al., 2011); underlying lack of interpersonal empathy (Cordier et al., 2010); Playfulness indicators: ADHD group “typical” with some difficult items but difficulty with basic skills (sharking) (Wilkes-Gillan et al., 2014); seek green outdoor settings at a higher rate (Taylor & Kuo, 2011)

For motor, Papadopoulos and his group (2018) found that there is some difficulty with handwriting. They also reported the higher ADHD and lower motor proficiency scores, the more sleep problems. The fact that Jeremy had sleep problems made me want to look at his motor skills for this reason. This is another interesting one. Children with parent-reported motor issues received more PT than those with teacher-reported motor issues. The fact that we listen to the parents more than the teachers about motor issues is important to consider. Under-treated motor problems in children with ADHD are really due to a behavioral focus so that is why it tends to get missed.

Sleep deficits negatively affect inhibitory control (Cremone-Caira et al., 2019). If we know that these kids have inhibition issues, we need to help them get some sleep. Poor sleep is only reinforcing their challenges and making it worse. They found that there were difficulties initiating and maintaining sleep at a rate of 20 to 50% of kids with ADHD (Corkum et al., 1998). Now, granted, that was 20 years ago, but they have replicated that since. And, if you have a sleep disorder, there is an 84.8% chance that it is negatively affecting your quality of life (Yurumez & Gunay Kilic, 2013).

Motor skills and executive functions are related. If you have some motor difficulties, it is going to influence your executive function ability (Pan et al., 2015). Boys with ADHD have lower executive function ability than typical peers on both performance-based and parent report tools, thus, it is really important that you use a combination of both performance and parent report tools (Sgunibu et al., 2012).

Children with ADHD are 50% less likely to participate in sports than children with asthma (Tanden et al., 2019). I find that amazing. Kids with ADHD also have a higher incidence of screen time usage, and we know that that is always a challenge (Tanden et al., 2019). Childhood ADHD is also associated with obesity. Hence, if you are not doing anything physical and you are sitting there watching your computer or playing video games, and you are impulsive, you are more likely to be obese (Kim et al., 2011). An underlying lack of interpersonal empathy can be something that you often see in ADHD. This affects social abilities and participation and success (Cordier et al., 2010). There are also playfulness indicators. An ADHD group might score as "typical" with some difficult play criteria, but then have more difficulty with basic items (Wilkes-Gillan et al., 2014). Their play may be developmentally out of whack. Again, they might be okay with some high-level types of behaviors, but then when it comes to something simple like taking turns or sharing, they cannot do it. Sometimes we have to go back and practice these rudimentary skills. This might be why they are struggling socially because they are having problems with age-inappropriate items. Lastly, these kids with ADHD really seek green outdoor settings at a higher rate (Taylor & Kuo, 2011). It would be interesting to monitor how outside time might influence their performance on assessments.

EF and Self-Regulation Connection

• Inhibitory control
• Cognitive/mental flexibility
• Working memory

Can these kids self-regulate? When they cannot, it does not work out well for them in school or at home, and it does not work out well in terms of social abilities. When they become adults, they have trouble keeping and maintaining a job. This is the definition of EF.

Some of you might be very familiar with this definition, but it is also quite complicated. This is how we remember information, filter distractions, resist impulses, and sustain attention during an activity that is also goal-directed. While we also adjust our plan as needed to avoid frustration in the process. That is a lot of working parts. Many times, you see people refer to executive functions like an air traffic controller of information and materials. These are the "big 3."

This is how we remember information, filter distractions, resist impulses, and sustain attention during an activity that is goal-directed while adjusting our plan as necessary and avoiding frustration!         

Miyake, A., Friedman, N. P., Emerson, M. J., Witzki, A. H., Howerter, A., & Wager, T. D. (2000). The unity and diversity of executive functions and their contributions to complex "frontal lobe" tasks: A latent variable analysis,  Cognitive Psychology, 41 , 49-100.

• Impulse Control
• socially acceptable (Olson, 2010)
• Ability to store, update and manipulate /process information over short periods of time (Best & Miller, 2010)
• “Limited-capacity information-processing system” (Roman et al., 2015)
• Verbal, visuospatial, and coordinating central executive
• Ability to think flexibly and shift perspective and approaches easily, critical to learning new ideas (different perspectives)
• Switching between two or more mental sets with each set containing several tasks rules
• Feedback related (unlike inhibition) (Best & Miller, 2010)

All these things are important, but the three basic dimensions are inhibitory control, which develops first around four years of age, cognitive and mental flexibility, and working memory. Mental flexibility is the result of inhibitory control and working memory working together. If you have a problem with inhibition or working memory, or both, you are going to have problems with cognitive flexibility. The flip side of that would be rigidity. It is also being able to shift your thinking in the moment back and forth. The flip side of that would be to be stuck. Working memory is the ability to use your memory functionally. It is very important to know that we only have a very limited amount of memory capacity, and it is all we have. I like to call my working memory my suitcase. You have to make sure you pack the right things in there for the trip that you are going on. If you pack your suitcase for Fiji and you are going to Alaska, you are going to be on the beach with boots and a parka and be miserable. It is really important that we pull in the information that we need. This takes sustained attention. If you cannot sustain your attention, you are not going to capture the right memories. And again, if there are problems with inhibitory control or impulse control, this is going to be challenging. Impulse control is controlling yourself in the moment. If I can string those together, now I have more self-regulation ability. Again, these are the big three: inhibition, working memory, and cognitive flexibility and shifting. 

I already explained these, but I want you to appreciate what the research says. Inhibition requires an arbitrary rule to be held in your mind while you are inhibiting one response to produce an alternative response, which is typically the one that is more socially acceptable. Working memory is storing, updating, and manipulating information over short periods of time. It has a limited capacity, and it is verbal and visuospatial. Then, for cognitive shifting and flexibility, there are two pieces to it. It is being open and being able to shift. Here is what is interesting. Cognitive flexibility and shifting respond really well to internal feedback. You can actually start to observe things and gain some insight and make changes. Why that is important is because inhibition does not get better from internal feedback. It only gets better from external feedback. Think about someone you know who interrupts a lot because they are impulsive. They see that they do it and do not change because no one has said anything to them. It requires external feedback for them to say, "Oh, I'm doing it wrong." We do not have this internal mechanism to change our impulsivity. We cannot assume these kids will figure it out and fix it, because they will not. We have to be very stern and to the point and say, "You're doing it wrong. This is why it's wrong and here's what you need to do instead." This is the key. Figure 4 is an executive function cheat sheet.

(Cooper-Kahn & Dietzel, 2008)

Figure 4.  EF cheat sheet.

This is from Cooper-Kahn and Dietzel (2008). They tell you the executive function, what the function is, and then the end dysfunction. For inhibition, the dysfunction is impulsive. If you cannot cognitively shift, you can get stuck. If you do not have emotional control, you are going to be over or under-reactive. If you cannot initiate a task, you are stuck in inertia. If you do not have a good working memory, you are lost. If you cannot plan and organize, you are fragmented. If you cannot manage your materials, you are chaotic. And then, if you cannot self-monitor, you are clueless. The red ones are those that Jeremy struggled with. He was impulsive, had inertia, was lost, and chaotic. He was also a little fragmented and had a difficult time with organization. However, these four things were his biggest challenges.

Review of Evidence-based Interventions for Case

One of the objectives is to talk about evidence and how we are going to use the evidence to support our intervention. I focused on motor, social, executive functions, and sleep. These are the things that were assessed that also had evidence for different intervention strategies (see Figure 5).

Figure 5.  Evidence-based interventions ((Hui Tseng, et al., 2004; Hahn-Markowitz et al., 2016; Washington University, n.d.;  Diamond & Lee, 2011; White & Carlson, 2016;  Winsler et al., 2009;  Marjorek et al., 2004; Kuhn & Floress, 2008; Frike et al, 2006; Keshavarzi et al., 2014).

Motor/Social Categories

Let's look at the motor and social categories. What is really interesting is that attention and impulse control are related to fine motor and gross motor coordination. If we can work on coordination, we can also increase attention and impulse control. This is killing two birds with one stone in Jeremy's case. I do not know who is familiar with Hebbian's law, but it says is that the (brain) cells that fire together wire together. One of the ways to do that is through the concept of anticipation. Anticipation builds memory capacity and will improve working memory. Anticipation is a context, and you can basically put anticipation in anything. With turn-taking, there is anticipation. If there is a competition, there is anticipation among the competitors. If you know you are going to be called on, there is anticipation. If you are playing a game where something might jump out, there is anticipation. These are just a few examples of where you can build in anticipation. If you can add that into your activities, you can build memory capacity. Another study looked at how table tennis exercises improved executive function and object control skills. Table tennis does not require a lot of heavy-duty cardio and it is not a tiring exercise, but it requires a lot of hand-eye coordination and sustained attention. I think this is a really good occupation-based strategy to improve executive function and object control. Physical activity also improves working memory. I have had tons of success with kids doing physical activity both in therapy and at home to improve their working memory. Some of the social strategies that work really for kids, and we will talk about a few in a little bit, is taking a peer's perspective and working on empathy and imagination. These things were really shown to be effective ways to change someone's social success.

Executive Function

For executive function, you have to give them external feedback. You have to tell them when they are being impulsive, and then you have to tell them how to fix it. These are kids who are on a very fast, impulsive temporal context. I talk to them about the hare versus the turtle. I tell them to be more like the turtle. Yoga, mindfulness, and visual imagery are other strategies. Yoga and mindfulness are occupations, and you can incorporate visual imagery into any occupation. They are so effective especially living in a very stressful, fast-paced society. There is self-distancing involved which we know also helps with the social skills for these kids. Systems thinking and routines with visuals are other options. The more visuals we use, the better for these kids.  If we can give them visual imagery, it helps. Here is an example of systems thinking. You have family coming over for Thanksgiving dinner. There are 17 people coming and three courses. Each dish takes this long and I need these ingredients for each. Additionally, these dishes all cook at different times so they come out at the right time. This is systems thinking. As a strategy, I gather my recipes and my materials and then put them in order for which ones I have to cook first and for how long. I form a little assembly line of what I am going to do. We can use this type of strategy for kids who struggle with material management and organization. It can be a game-changer. Other ideas include self-talk, martial arts, aerobics, and Montessori. I do not know if anyone has any experience with a Montessori approach. One of the reasons why it is effective is because Montessori uses self-distancing activities. Telling the kids what you want them to do instead of what you do not want them to do really works. It also includes structured routines that lead to self-regulation.

The last section shows that motor skills, as well as sleep hygiene, can improve sleep. Physical activity actually increases non-REM sleep. Deep pressure and proprioceptive can increase REM sleep. A sleep log is actually evidence-based as well. Shortly, I am going to describe a routine that works with kids that is evidence-based. All of these things here you can use as your evidence-based toolkit to work with kids with ADHD. 

Case Study Application- Improve ADLs

Top-down analysis.

Jeremy's goal is to have a timely morning routine which involves waking up, dressing, brushing teeth, and packing a backpack. This is a top-down analysis in Figure 6.

Figure 6.  Example of a top-down analysis for ADL routine.

When we use a top-down approach, we are starting with the actual occupation and the goal is to look at where this happens and in what context. I want you to think about where that would happen. In Jeremy's case, it is his bedroom and bathroom. Activity analysis is the bread and butter of OTs. His routine consists of waking up, dressing, brushing his teeth, and packing a backpack. During this analysis, we want to see what he can do and what he cannot do. What are some of your thoughts? Here are some answers from our audience:

• Being aware of time during all tasks/Using a timer. You are seeing a discrepancy between time awareness, time estimation, time monitoring, and time management. I would agree with you that he probably has a hard time all of those.
• Packing the backpack. We know that he is sleepy in the morning and he has a difficult time staying organized. This is especially true if he is half asleep or stressed in the morning.
• Finding his folders. Folders can be elusive sometimes to these kids, so that is a great point. Folders can be found in very strange places.
• Hygiene/organization. Even in hygiene, it is important to make sure that they are organized.

I used a PEO or person-occupation-environment perspective here. We started with some physical activity in the morning to help him to wake up. We did yoga. I asked, "What would Batman do?" He was a big Batman guy. We did some self-distancing by him coming up with strategies for Batman. Or, we used a wresting theme. These activities helped him to be more alert and be able to increase his attention.

We also used a task strip with positive reinforcement to help him see what he needed to do. Visuals can be very helpful for these kids.

Then, we used minimal distractions. We set things out the night before and used that visual so he could match things. We also devised a place where his folders could go. This all might seem trivial, but it really matters for this type of kid. The timer helps as well. You can make it a game.

Activities to Improve ADLs

• Focus on physical activity, motor skills with automaticity and incorporate aspects of yoga to increase sustained attention and memory
• Visual supports and routine with structure
• Self-talk and self-distancing strategies
• Positively reward

To improve ADLs, the key is to focus on physical activity and motor skills with the goal of automaticity. For example, we can incorporate yoga to increase sustained attention and memory. As we talked about earlier, visual supports and structured routines are other great ideas. I cannot emphasize enough the idea of self-talk. This helps with self-regulation and impulsivity on a lower level. The ability to "self-talk" should be pretty solid for kids around the age of seven, but the kids that we are talking about lack this skill. Self-distancing, or having them give strategies to someone other than themselves, is also great. Let them problem-solve and talk it through for someone else, like Batman or John Cena. This way they do not feel like they are picking on themselves or feeling pressured to figure it out for themselves. They are figuring out for someone else, and this strategy is evidence-based. We often forget to positively reward these kids. I like to do something like time with mom and dad, I develop short-term and long-term rewards with mom and dad. For example, Jeremy wanted a wrestling figure for his long term reward. But on a daily basis, he got wrestling bucks and that bought time to wrestle with dad on the weekends.

Case Study Application- Finish a Task with Necessary Supplies

Figure 7. Example of a top-down analysis for finishing a task with necessary supplies.

The next goal is to finish a task with the necessary supplies. You can fill in whatever task that he needed to do like homework, hygiene, or whatever it was with the necessary supplies. Typically, he would start something and then not have all the supplies he needed. He would then run to go get something and then lose track of what he was doing. Activities would not get done and then there would be a mess. We want to know when this would happen and the context. What is required of that activity, and then what can he do versus what he cannot do? Those are the discrepancies.

As I stated a few moments ago, he tends to not have the needed materials. That is the first issue right out of the gate. And because he is impulsive, he starts doing something else. Eventually, he does not finish anything due to a lack of persistence and distractibility. From a personal standpoint, we could work on using motor tasks for increased attention. We know that fine motor and gross motor tasks are going to help. We could also look at using coordination tasks, self-talk, and distancing. Cognitive training is also evidence-based. Can they start to use a checklist or something to create a better strategy?

Then, from an occupation standpoint, again we can use visuals and break down the task. We can also use a tracking system that we are going to go over in just a second.

From an environmental aspect, we can encourage the use of quiet areas to help with sustained attention and better memory. Here we can also use some visual supports or a Montessori approach. "This is what the task is supposed to look like when I am finished." If we have a task, what does the end result look like so that the person knows? And even better, what are the supplies pictured so I know what I have to get first, and then I know what the end result should look like. That is super helpful for someone who is so disorganized when putting materials together.

Activities for Completing Tasks

• Inhibition: Self-talk, slowing down, self-distancing, external feedback
• WM: physical activity
• Attention: physical activity
• Using environmental strategies and visuals to support
• Behavioral: task breakdown, positive reinforcers
• Occupation-based is imperative!

We want to use occupation-based tasks, but we want them to be fun and let the child make a choice. When things are getting easier, we can then move toward less preferred tasks. For example, we do not want to start with homework.

Case Study Application: Social

• Involve a peer or sibling
• Play-based model:
• Capture intrinsic motivations (WWE)
• Empathy focus
• Arrange the environment to foster mutually enjoyable social interaction and imagination
• Teaching social play language and reading expressive body language (can use dogs and their behavior)
• Incorporate parents and coach them so they can coach outside of therapy

(Cordier et al., 2009; Wilkes-Gillan et al., 2016)

There is a play-based model that is evidence-based. They recommend involving a peer or sibling. This play-based model focuses on intrinsic motivation. With Jeremy, we could do wrestling. We could focus on empathy. It is important to arrange the environment so that it is mutually enjoyable. We need to teach social play language and reading expressive body language. The evidence was interesting as it said to use dogs because it could help the child start to read behaviors. Dogs are a little bit easier than people. Jeremy loves dogs so that would work. You could then incorporate parents in order to coach him outside of therapy. They found that to be very successful.

Case Study Application: Sleep

• Turn off electronics 2 hours prior
• Hot bath or shower
• PJs prepped
• Boardgame in room
• Read in bed (parents, then alone
• Highlights with organizer, feelings
• Token reward system
• Flexibility on weekends
• Sleep logs are evidence-based
• Physical activity during day imperative 

(Kuhn & Floress, 2008; Fricke et al., 2006)

For sleep, this is the protocol that is highly recommended for these kids. You should turn electronics off two hours prior. Do not shoot the messenger. I know that is really easier said than done. Another protocol is to have the child take a hot bath or shower. They need to have their pajamas prepared. It is a stimulus that can help them progress through the routine. They can do a board game in the room. Another activity is reading in bed. It can start out with the parents reading and then progress to the child reading alone. They can also organize their thoughts and feelings throughout the day. It will help the brain calm down. A token reward system is another great strategy. Make sure to incorporate flexibility on the weekends. It is ok. Sleep logs are evidence-based. And again, physical activity during the day really works.

Systems and Organization

This information is what we already talked about, but I wanted to give you a good resource as well in Figure 8. 

Great resource: https://www.understood.org/~/media/040bfb1894284d019bf78ac01a5f1513.pdf

Figure 8.  Systems and organization examples.

I like the idea of a mental movie approach. If they are piler and not a filer, we have to appreciate that and try to use things that can help them. This may be an accordion folder or something like that.

Self-Monitoring: GOAL Attainment Scaling

This is the idea of a Goal Attainment Scale (see Figure 9). It is a strategy to identify changes in academic and social behavior. It creates habits and routines.

Figure 9.  Goal Attainment Scale overview.

The way that you do it is you select the target behavior. You describe that behavior outcome in objective terms and then you develop three to five (I typically use five) descriptions of probable outcomes from least favorable to most favorable.

Figure 10.  Numerical ratings for the Goal Attainment Scale.

These are some options that you can use, frequency, quality, usage, percent complete. 

• Frequency (Never–Sometimes–Very Often–Almost Always–Always)·
• Quality (Poor–Fair–Good–Excellent)·
• Development (Not Present–Emerging–Developing–Accomplished–Exceeding)·
• Usage (Unused–Inappropriate Use–Appropriate Use–Exceptional Use)·
• Timeliness (Late–On-Time–Early)·
• Percent complete (0%–25%–50%–75%–100%)·
• Accuracy (Totally Incorrect–Partially Correct–Totally Correct)·
• Effort (Not Attempted–Minimal Effort–Acceptable Effort–Outstanding Effort)·
• Amount of Support Needed (Totally Dependent–-Extensive Assistance–Some Assistance–Limited Assistance–Independent)·
• Engagement (None–Limited–Acceptable–Exceptional)

This is what the five looks like. You have two choices. You can do a baseline here at zero or the baseline at minus two where that is the worst with no change. Or, you can start at their baseline here at two and only go up. If they cannot handle seeing that they went down, you might choose that option instead. We do not want any negative things causing them anxiety. I have also listed the actual ratings. Here is the example for our friend Jeremy in Figure 11.

Figure 11.  GAS scale example for Jeremy.

He wanted to perform his AM routine within 20 minutes according to his mom. On the first date, he was a +1, which is he did only 75% within 20 minutes. On Day 2, he had 50% of his stuff done within 20 minutes. Day three, he had only 25% done. On four, he was back up to 75%. Day five, he did everything in 20 minutes. Day six, he was back to 75%. And then you see on days seven and eight, he actually met his goal. And on day nine, he almost met his goal. Once you plot the dates you have a graph. This shows change over time and whether or not things are working. You can also do this at home to capture the change in a more specific and sensitive way. On that note, we focused on time.

Thanks for joining me today. I hope you find the information helpful. Feel free to reach out to me if you have any questions.

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Quint, N. (2020).   Pediatric case study: Child with ADHD.   OccupationalTherapy.com, Article 5145 . Retrieved from http://OccupationalTherapy.com

Nicole Quint has been an occupational therapist for over 15 years, currently serving as an Associate Professor in the Occupational Therapy Department at Nova Southeastern University, teaching in both the Masters and Doctoral programs. She provides outpatient pediatric OT services, specializing in children and adolescents with Sensory Processing Disorder and concomitant disorders. She also provides consultation services for schools, professional development, and special education services. She provides continuing education on topics related to SPD, pediatric considerations on the occupation of sleep, occupational therapy and vision, reflective therapist, executive functions, leadership in occupational therapy and social emotional learning.

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Evidence-based approaches: a pediatric perspective of the occupation of sleep, course: #6204 level: intermediate 2 hours, pediatric case study: child with oculomotor and perceptual challenges, course: #4536 level: intermediate 1 hour, from meltdowns to an occupation-centered approach for self-regulation and management, course: #6106 level: intermediate 2 hours, course: #4577 level: intermediate 1 hour, motor skill acquisition for optimal occupational performance, course: #3747 level: introductory 1 hour.

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Patient Case #1: 19-Year-Old Male With ADHD

• Craig Chepke, MD, DFAPA, FAPA
• Andrew J. Cutler, MD

Stephen Faraone, PhD, presents the case of a 19-year-old male with ADHD.

EP: 1 . Prevalence of Adult ADHD

Ep: 2 . diagnosis and management of adults adhd compared to children.

EP: 3 . Diagnosing Adults With ADHD Based on Patient Presentation

EP: 4 . Unmet Needs in the Treatment of Adult ADHD

EP: 5 . Efficacy and Safety of Treatment Options Utilized in Adult ADHD

Ep: 6 . future of adult adhd, ep: 7 . patient case #1: 19-year-old male with adhd.

EP: 8 . Patient Case #1: Prompting an ADHD Consultation

Ep: 9 . patient case #1: differentiating between adhd and other psychiatric comorbidities, ep: 10 . patient case #1: co-managing adhd, ep: 11 . patient case #1: dealing with treatment delay in adult adhd, ep: 12 . patient case #2: a 23-year-old patient with adhd, ep: 13 . patient case #2: impressions and challenges in adult adhd, ep: 14 . patient case #2: dealing with comorbidities in adult adhd, ep: 15 . patient case #2: addressing non-adherence and stigma of adult adhd, ep: 16 . patient case #2: importance of an integrative approach in adult adhd, ep: 17 . case 3: 24-year-old patient with adhd, ep: 18 . case 3: treatment goals in adult adhd, ep: 19 . case 3: factors driving treatment selection in adult adhd, ep: 20 . implications of pharmacogenetic testing in adhd, ep: 21 . novel drug delivery systems in adhd and take-home messages.

Stephen Faraone, PhD: That's a good one, yes, I'd like that, it's a very creative one, thank you, thank you. OK, let's move on to the case presentation. This first patient is a 19-year-old male, who presented to his psychiatrist after being referred by his primary care provider, PCP for ADHD consultation, during the interview, he noted he was a sophomore in college and is taking 17 credits. This semester chief complaint includes a lack of ability to focus in class as well as struggling with time management. He complained that every time he's in class, he finds himself thinking about many other responsibilities he must complete at home and feels that he cannot control it. He has had this complaint for the past 6 years, but refused to seek help, because he feared being put on medication. In high school, he was assigned a counselor who taught him behavior techniques such as making a schedule, and going on walks, which he found to be very effective. However, these techniques were less effective once he started college. His symptoms tend to get worse before exams, he often feels very anxious, leading to horrible performance on exams, he claimed that he has been this anxious since he took his LSAT tests. Currently, he is on academic probation, and is not allowed to be part of the Student Work Program, which was his only source of income. The patient has no history of substance abuse, no history of taking any medications for his symptoms, and no history of suicidal thoughts.

Transcript edited for clarity

WHO Addresses Gaps in Mental Health Care Delivery and Quality

Treating ADHD in Children: Concerns, Controversies, Safety Measures

Childhood Physical Health and ADHD Symptoms

ADHD in Older Adults

Longitudinal Study Looks at Risk of Cardiovascular Disease With Long-Term ADHD Medication Use

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Case Report: Treatment of a Comorbid Attention Deficit Hyperactivity Disorder and Obsessive–Compulsive Disorder With Psychostimulants

Associated data.

The data analyzed in this study is subject to the following licenses/restrictions: identifying/confidential patient data cannot be shared. Requests to access the data should be directed to the corresponding author.

Introduction: Attention deficit hyperactivity disorder (ADHD) is a common disease in childhood and adolescence. In about 60% of pediatric patients, the symptoms persist into adulthood. Treatment guidelines for adult ADHD patients suggest multimodal therapy consisting of psychostimulants and psychotherapy. Many adult ADHD patients also suffer from psychiatric comorbidities, among others obsessive–compulsive disorder (OCD). The treatment of the comorbidity of ADHD and OCD remains challenging as the literature is sparse. Moreover, the impact of psychostimulants on obsessive–compulsive symptoms is still unclear.

Case Presentation: Here, we report on a 33-year-old patient with an OCD who was unable to achieve sufficient remission under long-term guideline-based treatment for OCD. The re-examination of the psychological symptoms revealed the presence of adult ADHD as a comorbid disorder. The patient has already been treated with paroxetine and quetiapine for the OCD. Due to the newly established diagnosis of ADHD, extended-release methylphenidate (ER MPH) was administered in addition to a serotonin reuptake inhibitor. After a dose of 30 mg ER MPH, the patient reported an improvement in both the ADHD and the obsessive–compulsive symptoms. After discharge, the patient reduced ER MPH without consultation with a physician due to subjectively described side effects. The discontinuation of medication led to a renewed increase in ADHD and obsessive–compulsive symptoms. The readjustment to ER MPH in combination with sertraline and quetiapine thereafter led to a significant improvement in the compulsive symptoms again.

Conclusion: The present case shows that in ADHD and comorbid obsessive–compulsive disorder, treatment with psychostimulants can improve the obsessive–compulsive symptoms in addition to the ADHD-specific symptoms. To our knowledge, this is only the second case report describing a treatment with ER MPH for an adult patient with OCD and ADHD comorbidity in the literature. Further research, especially randomized controlled trials, is needed to standardize treatment options.

Introduction

Attention deficit hyperactivity disorder (ADHD) is a frequent mental disorder with childhood onset and a worldwide prevalence of at least 2.8% ( 1 ). It is characterized by the three core symptoms of attention deficit, hyperactivity, and impulsivity manifesting since childhood ( 2 ). Adult ADHD is also commonly associated with different comorbidities ( 3 , 4 ), particularly obsessive–compulsive disorder (OCD). The prevalence of OCD comorbidity in patients with ADHD varies widely in the literature, ranging from 1 to 13% ( 5 ). On the other hand, ADHD prevalence in patients with OCD has been reported as ranging from 0 to 23% ( 5 ). The high co-occurrence of these disorders has raised questions about their diagnoses, neurobiology, and treatment.

It has been discussed that the ADHD-like symptoms in OCD, for example inattention, may have contributed to the inconsistency of the reported co-occurrence rates. Furthermore, familial link between OCD and ADHD, disturbances in attention, and executive function and the high comorbidity of tic disorders are common features of these two disorders ( 6 – 9 ).

On the other hand, these disorders have reverse fronto-striatal abnormalities ( 5 ). OCD patients exhibit increased fronto-striatal activity and functional connectivity ( 5 ). In contrast, ADHD is found to be associated with hypoactivity in the prefrontal and striatal brain regions and a reduced fronto-striatal activity ( 5 ). Despite these differences, a shared dysfunction in the medio-fronto-striato-limbic brain region was reported in addition to disorder-specific dysfunctions ( 10 ).

Psychostimulants such as methylphenidate are regarded as the first-line treatment for ADHD. They increase prefrontal activation and improve both clinical symptomology and neurocognitive functioning in ADHD by modulating dopamine reuptake. Guidelines for the treatment of OCD recommend serotonin reuptake inhibitors as first-line pharmacotherapy, which are thought to modulate fronto-striatal hyperactivity. In the case of partial response to serotonin reuptake inhibitors, an augmentation therapy with antipsychotics has also been shown to have a useful effect ( 11 ).

Although the pharmacotherapy of each of these disorders has been well-established, the effective treatment and management of patients with comorbid ADHD and OCD remains challenging. While stimulant medication is recommended as the first-line treatment for ADHD, findings suggest that its use in OCD may exacerbate the OCD symptoms. To our knowledge, there have been only a few studies, mostly case reports and case studies, reporting on the pharmacotherapy of this comorbidity. Some of these reports have shown that the use of stimulants may cause obsessive–compulsive symptoms as side effects ( 12 – 14 ), while others have reported a decline of OCD symptoms under stimulant therapy ( 15 , 16 ).

In this report, we present a case of an adult patient with comorbid ADHD and OCD treated successfully with stimulants and serotonin reuptake inhibitors.

Case Presentation

In November 2017, a 33-year-old patient presented at our ADHD outpatient clinic in the Department of Psychiatry and Psychotherapy at the University Hospital of Leipzig for diagnostic clarification. During a previous psychiatric examination organized by the federal employment agency, a tentative ADHD diagnosis was made for the first time. The patient reported impulsiveness and physical restlessness that had persisted since childhood. He stated that he could hardly sit still or stay in one place for a longer period of time. He also described a lack of concentration and problems sustaining attention in given tasks (see Table 1 for the summary of clinical manifestations). In order to relax physically, he started practicing martial arts and has been doing a lot of gardening lately.

Summary of the clinical manifestations of ADHD and OCD.

ADHD, attention deficit hyperactivity disorder; OCD, obsessive–compulsive disorder .

A mental status examination was conducted according to the AMDP System ( 17 ). The patient was oriented with regard to time, place, person, and situation. He was friendly and cooperative in personal contact. In motor activity, he demonstrated restlessness (fidgeting with the legs, playing with the fingers, and partly increased body tension). He described his mood as slightly dysphoric; his affect was broad. He showed no evidence of delusions, hallucinations, or ideas of reference, but he had poor impulse control, attention deficits with quick distractibility, as well as concentration and short-term memory problems. The thought process was lightly circumstantial, but apart from that without a pathological finding. He did not display any sleep or eating disorders. Any kind of suicidal ideations were denied. The patient demonstrated insight into his mental disorder and was motivated for therapy. These aspects were also confirmed by a senior psychiatrist.

In further exploration, the patient stated that he had been suffering from an OCD since about the age of 10. At that time, a classmate had had an eye tumor, and in this context, he had first developed a washing compulsion for which a first presentation to a psychiatrist had taken place. Later on, he showed compulsive behavior in the form of compulsive counting and ritualized touching things and obsessive thoughts (fear of aliens and the special meaning of the color “blue”). These obsessions began after he watched a film about aliens as a teenager, which frightened him enormously although he does not believe in aliens. Overall, obsessive and compulsive symptoms have been affecting his life in many ways, but especially his work life, disrupting his functionality. He had been treated as an inpatient and outpatient several times, yet the OCD symptoms would still occupy 3–4 h per day (see Table 1 ). In addition, ambulatory psychotherapy (anamnestically cognitive behavioral therapy) had only helped him to a limited extent. However, the existing concentration problems were described as independent of obsessive–compulsive disorder. The current medication at the first visit consisted of paroxetine 30 mg/day and quetiapine 100 mg/day.

The patient also reported that, in the past, he had been drinking a lot of alcohol to compensate for his compulsions and impulsiveness. However, alcohol had disinhibited him in parts even more, and it had come to physical confrontations several times. He had lost control in situations in which he felt provoked. In the past, criminal proceedings had also been brought against him in this context. In the course of time, he developed an alcohol addiction. At the time of the first visit to our outpatient clinic, he had been completely abstinent from alcohol for 6 years. Drug consumption was also negated, which could also be confirmed by a toxicological screen at the inpatient admission.

The following information was gathered on the past psychiatric history: a first inpatient treatment because of the OCD (ICD-10: F42.2) took place in 2006. During that time, a suspected diagnosis of paranoid schizophrenia (ICD-10: F20.0) was made and treatment with risperidone 1.5 mg/day, olanzapine 10 mg/day, and lorazepam 1 mg/day was started. Risperidone was discontinued due to akathisia, and the patient was then treated with olanzapine 10 mg/day and paroxetine 20 mg/day. In 2008, the patient was treated in a day clinic for 1.5 months, where an OCD (ICD-10: F42.2) and an immature personality accentuation were diagnosed. During this treatment, the dose of sulpride was increased from 200 to 400 mg/day, which was prescribed during the outpatient treatment. Subsequently, sulpride was switched to paroxetine 60 mg/day. In 2009, the patient was hospitalized again due to worsening of the OCD symptoms. In 2012, an alcohol withdrawal treatment was completed. The discharge medication consisted of paroxetine 60 mg/day and olanzapine 10 mg/day. The diagnoses then consisted of alcohol dependence (ICD-10: F10.2), alcohol withdrawal syndrome (ICD-10: F10.3), OCD (ICD-10: F42.2), personality accentuation (ICD-10: F60.9), and an unspecified form of schizophrenia (ICD-10: F20.8). In 2013, another alcohol withdrawal treatment due to a relapse followed. Since then, he has been abstinent of alcohol according to his own statement. Discharge medication consisted of paroxetine 60 mg/day and promethazine 25 mg as needed. Since 2015, the patient has been undergoing an outpatient behavioral therapy treatment, without achieving complete remission of the OCD so far.

While there were no relevant diseases in the medical anamnesis, the family history revealed that his mother had been diagnosed with schizophrenia and his father had a history of alcohol addiction.

After the initial presentation in our outpatient clinic (December 2017), detailed diagnostic tests were performed, including the Diagnostic Interview for ADHD in adults (DIVA) and ADHD-specific questionnaires [Conners Adult ADHD Rating Scales (CAARS)—Self-Report: Long Version ( 18 ), Wender Utah Rating Scale (WURS), and Adult ADHD—Self-Report Scale (ADHD-SB)] as well as other questionnaires (e.g., Personality Styles and Disorder Inventory). The subjective assessment of ADHD-relevant symptoms was clearly significant in terms of inattention and hyperactivity, as well as temperament, affective instability, emotional overreaction, and impulsiveness. The CAARS revealed an ADHD index in percentile rank of 88, a DSM-IV Inattentive symptom scale in percentile rank of 98, a DSM-IV Hyperactive–Impulsive scale in percentile rank of 86, and a DSM-IV ADHD Symptoms Total in percentile rank of 96 (see Table 2 ). Available school reports were also reviewed: in primary school reports, the patient was described as an eager and endeavored student, who was partly distracted and showed fluctuations in cooperation with other students. A somewhat unfriendly behavior toward classmates was also reported. These descriptions were in accordance with the self-report of the patient and indicate the presence of ADHD in childhood. The available findings as well as the biographical and current anamnesis strongly suggested the diagnosis of ADHD in adulthood.

The patient's scores on CAARS (in percentile rank) and Y-BOCS.

ADHD, attention deficit hyperactivity disorder; ER MPH, extended-release methylphenidate; CAARS, Conners adult ADHD rating scales; DSM-I, DSM-IV inattentive symptoms; DSM-Hy/I, DSM-IV hyperactive–impulsive symptoms; DSM-Total, DSM-IV ADHD symptoms total; Y-BOCS, yale–brown obsessive compulsive scale .

Due to the complex comorbidity of psychiatric illnesses, the patient was admitted to our inpatient unit in January 2018 for medication adjustment. At that time, the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) ( 19 ) was performed to assess the severity of the OCD symptoms. Concerning the last 7 days, the patient affirmed seven out of 37 typical obsessive thoughts and seven of 21 typical compulsive behaviors. In the severity rating, the patient reached a total score of 18 points, of which eight points were scored in the obsessive thoughts scale and 10 points were on the compulsive behavior scale. The laboratory tests showed a mild folic acid deficiency, which was substituted accordingly. Electrocardiography, electroencephalography, as well as magnetic resonance imaging of the brain showed no abnormal findings.

In accordance with existing literature, we switched the medication from paroxetine 30 mg to sertraline 50 mg/day because of the lack of therapy response to paroxetine treatment for many years ( 20 , 21 ). A psychostimulant treatment with extended-release methylphenidate (ER MPH) was initiated. ER MPH was gradually dosed up to 30 mg/day. Under this medication, not only the ADHD symptoms but also his OCD symptoms improved, so that sertraline could subsequently be reduced to 25 mg/day. At this time, the patient stated that his OCD had almost completely disappeared and that the time he spent with obsessive thoughts and compulsive actions had decreased severely. Furthermore, he felt more balanced and reported that he did not get into conflicts so quickly anymore. As the restlessness decreased, quetiapine could also be reduced and eventually stopped.

One day before discharge (after 42 days on board), Y-BOCS and CAARS were applied again. The patient reported observing one out of 37 typical obsessive thoughts and one of 21 typical compulsive behaviors in the last 7 days. In the severity rating, the patient reached a total score of seven points (five points for obsessive thoughts and two points for compulsive behavior). The CAARS resulted in an ADHD index in percentile rank of 5, a DSM-IV Inattentive symptom scale in percentile rank of 10, a DSM-IV Hyperactive–Impulsive symptom scale in percentile rank of 14, and a DSM-IV ADHD Symptoms Total in percentile rank of 10 (see Table 2 ). The medication at discharge consisted of ER MPH 30 mg/day and sertraline 25 mg/day.

After discharge, the patient attended our ADHD outpatient clinic for regular follow-ups. On his first visit (1 day after the discharge), he reported a good response to the medical therapy with ER MPH and assured that he did not notice any side effects. He expressed the wish to increase the sertraline dose from 25 to 37.5 mg/day. In the following visit after 26 days, the patient reported unspecific anxiety and panic attacks and claimed to have reduced ER MPH to 10 mg on his own responsibility after having read the package leaflet and worrying about potential side effects. Thus, the remaining medication consisted of sertraline 50 mg/day and quetiapine 25 mg/day, which he started again without a consultation with our outpatient clinic.

In March 2018, a month later after the discharge, a second inpatient admission was initiated after an emergency contact of the patient with the ward. He described an increase in obsessive–compulsive symptoms and restlessness and reported that he suffered from panic attacks and sleep disorders and that he lost his appetite. The patient observed severe mood swings and distrust toward other people. The medication at administration consisted of ER MPH 10 mg/day, sertraline 37.5 mg/day, and quetiapine 25 mg as needed. However, he reported that he did not want to continue to take ER MPH. Therefore, therapy with atomoxetine was started as ER MPH was discontinued. Due to the worsened symptomatology, the sertraline dose was increased to 150 mg/day and quetiapine was dosed up to 125 mg/day. However, the OCD symptoms worsened further after the discontinuation of ER MPH despite increasing the doses of sertraline and quetiapine. After weighing up the symptoms before and after treatment with ER MPH, we decided together with the patient to restart the treatment with ER MPH. Physical well-being and a reduction of the OCD and ADHD symptoms were described after switching the medication from atomoxetine to ER MPH. On the first day of the switch, we performed Y-BOCS and CAARS again. For the last 7 days, the patient reported observing four of 37 typical obsessive thoughts and four of 21 typical compulsive behaviors. In the severity rating, the patient reached a total score of 20 points, of which 11 points were on the scale of obsessive thoughts and nine points were on the scale of compulsive behavior. The CAARS showed an ADHD Index in percentile rank of 76, a DSM-IV Inattentive symptom scale in percentile rank of 54, a DSM-IV Hyperactive–Impulsive scale in percentile rank of 82, and a DSM-IV ADHD Symptoms Total in percentile rank of 69 (see Table 2 ).

An improvement of compulsive thoughts and joyfulness was observed when sertraline was added. The patient was discharged in April 2018 (after 27 days on board) into outpatient care at the ADHS outpatient clinic. Five days after discharge, CAARS and Y-BOCS were performed again: the patient reported observing two of 37 typical obsessive thoughts and four of 21 typical compulsive behaviors within the last 7 days. In the severity rating, the patient reached a total score of 18 points, of which 10 points were on the scale of obsessive thoughts and 8 points were on the scale of compulsive behavior. The CAARS revealed an ADHD Index in percentile rank of 42, a DSM-IV Inattentive symptom scale in percentile rank of 38, a DSM-IV Hyperactive–Impulsive scale in percentile rank of 35, and a DSM-IV ADHD Symptoms Total in percentile rank of 35 (see Table 2 ). Discharge medication consisted of ER MPH 10 mg/day, quetiapine 125 mg/day, and sertraline 200 mg per/day. A timeline of this case presentation is shown in Figure 1 .

Timeline of events and medication.

Discussion and Conclusions

In this case report, we present a case of successful treatment with psychostimulants in an adult patient with ADHD and comorbid OCD. Due to the late diagnosis of ADHD (in addition to an apparent misdiagnosis of schizophrenia and personality disorder), no effective treatment was initiated in his early life, resulting in an impacted quality of life up to now. After diagnosing ADHD, we treated the patient with ER MPH in addition to antidepressants for OCD treatment and observed that the adjunctive use of ER MPH resulted in enhanced treatment response. Contrary to reports in the literature, treatment with a stimulant did not cause a worsening of the OCD symptoms. Rather, the patient reported a severe decrease in OCD symptoms, which was also observable by the treatment team. A second administration was necessary due to a worsening of the OCD and ADHD symptoms occurring after the patient had reduced the dose of ER MPH on his own, because he was worried about side effects, which he had never actually experienced during the inpatient treatment. This case highlights the importance of frequent reassessment of comorbid conditions in the case of low treatment response to serotonin reuptake inhibitors and psychotherapy in patients with OCD. Untreated ADHD as a comorbid condition to OCD may reduce the treatment response on the OCD, as shown in previous studies ( 22 ).

Recognizing ADHD and OCD comorbidity is important for the clinical course of these disorders considering that the onset of OCD is significantly higher in adults with childhood ADHD symptoms and that the comorbidity is associated with more severe OCD symptoms and their persistence ( 23 , 24 ). Despite the increasing awareness and interest in ADHD, many affected adults are still underdiagnosed and untreated ( 25 ). The overlap of ADHD symptoms with several other psychiatric disorders, including mood disorders, substance abuse, and anxiety, and the high incidence of comorbid psychiatric conditions are probable reasons for the high number of missed ADHD diagnoses in adults ( 1 , 4 ).

On the basis of neuroimaging findings, structural and functional abnormalities in ADHD and OCD have been reported ( 26 ). A shared dysfunction in the mesial frontal cortex has been shown in patients with ADHD and OCD. On the other hand, disorder-specific dysfunctions were found in the caudate, cingulate, and parietal brain regions in patients with ADHD and in the lateral prefrontal cortex in OCD patients ( 27 ). Furthermore, fronto-striatal hypoactivity was observed in ADHD, whereas OCD shows fronto-striatal hyperactivity, which is also associated positively with symptom severity ( 10 ). Regarding structural abnormalities, a recent meta-analysis reported that patients with OCD have larger insular–striatal regions, whereas patients with ADHS have smaller ventrolateral prefrontal/insular–striatal regions ( 28 ). Nonetheless, apart from these disorder-specific abnormalities, both disorders show a similar neuropsychological impairment in executive functions.

Despite the high prevalence of OCD and ADHD comorbidity, only a few reports on the treatment of this comorbidity exist. Most of these studies were performed in child and adolescent populations, and as far as we know, only one was conducted in an adult population ( 14 ). Some of the case reports described obsessive–compulsive symptoms as a side effect of MPH treatment in patients with ADHD ( 12 – 14 , 29 – 32 ). However, a few studies also described a decrease of the obsessive–compulsive symptoms with MPH treatment ( 15 , 16 ). The latter results are in line with our findings. Still, there are no longitudinal and clinical controlled trials investigating the effect of MPH on the treatment of ADHD and OCD comorbidity. Although this case presentation is the first published report of a positive effect of ER MPH for the treatment of ADHD and OCD comorbidity in an adult patient, it also has certain limitations. This case report describes only one patient and a psychostimulant treatment with ER MPH in addition to the therapy with sertraline and quetiapine instead of a monotherapy. Also, it cannot be determined whether the patient took his medication regularly as prescribed after the first discharge.

The present case report highlights that treatment with psychostimulants in addition to a serotonin reuptake inhibitor can improve the obsessive–compulsive symptoms as well as the ADHD-specific symptoms in patients with ADHD and OCD comorbidity. Still, the treatment of this comorbidity remains challenging. Underdetection, misdiagnosis, as well as delay in the diagnosis of this comorbidity may cause a reduction in quality of life and low treatment response. Treating both disorders concurrently may help to decrease the symptom severity of both conditions. Monitoring the progress may also support the treatment process, allowing improvement of the treatment compliance as well as observing side effects. Yet, longitudinal and clinical controlled trials are needed to gain more information about the treatment of this comorbidity and to observe the treatment response longitudinally.

Data Availability Statement

Ethics statement.

Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author Contributions

ED-S and MS were the main authors of the manuscript. ED-S performed the literature research on the comorbidity of ADHD and OCD. Both authors participated substantially in the writing and editing of the final manuscript.

Conflict of Interest

MS has received speaker fees from Lilly, Medice Arzneimitte Pütter GmbH & Co. KG and Servier and was an advisory board member for Shire/Takeda. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We acknowledge support from the German Research Foundation (DFG) and Leipzig University within the program of Open Access Publishing. We thank Tina Stibbe for her English editing.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2021.649833/full#supplementary-material

• Second Opinion

Attention-Deficit/Hyperactivity Disorder (ADHD) in Children

What is ADHD in children?

Attention-deficit/hyperactivity disorder (ADHD) is a behavior disorder. It's also called attention deficit disorder. It's often first diagnosed in childhood. There are 3 types:

ADHD, combined. This is the most common type. A child is impulsive and hyperactive. He or she also has trouble paying attention and is easily distracted.

ADHD, impulsive/hyperactive. This is the least common type of ADHD. A child is impulsive and hyperactive. But he or she doesn't have trouble paying attention.

ADHD, inattentive and distractible. A child with this type is mostly inattentive and easily distracted.

What causes ADHD in a child?

The exact cause of ADHD is unknown. But research suggests that it is genetic. It is a brain-based problem. Children with ADHD have low levels of a brain chemical (dopamine). Studies show that brain metabolism in children with ADHD is lower in the parts of the brain that control attention, social judgment, and movement.

Which children are at risk for ADHD?

ADHD tends to run in families. Many parents of children with ADHD had symptoms of ADHD when they were younger. The condition is often found in brothers and sisters within the same family. Boys are more likely to have ADHD of the hyperactive or combined type than girls.

Other things that may raise the risk include:

Cigarette smoking and alcohol use during pregnancy

Exposure to lead as a young child

Brain injuries

Low birth weight

What are the symptoms of ADHD in a child?

Each child with ADHD may have different symptoms. He or she may have trouble paying attention. A child may also be impulsive and hyperactive. These symptoms most often happen together. But one may happen without the others.

Below are the most common symptoms of ADHD.

Inattention

Has a short attention span for age

Has a hard time listening to others

Has a hard time attending to details

Is easily distracted

Is forgetful

Has poor organizational skills for age

Has poor study skills for age

Impulsivity

Often interrupts others

Has a hard time waiting for his or her turn in school or social games

Tends to blurt out answers instead of waiting to be called on

Takes risks often, and often without thinking before acting

Hyperactivity

Seems to always be in motion; runs or climbs, at times with no clear goal except motion

Has a hard time staying in a seat even when it is expected

Fidgets with hands or squirms when in a seat

Talks a lot

Has a hard time doing quiet activities

Loses or forgets things repeatedly and often

Is not able to stay on task and shifts from one task to another without completing any

These symptoms may look like other health or behavior problems. Keep in mind that many of these symptoms may happen in children and teens who don’t have ADHD. A key part in diagnosis is that the symptoms must greatly affect how the child functions at home and in school. Make sure your child sees his or her healthcare provider for a diagnosis.

How is ADHD diagnosed in a child?

A pediatrician, child psychiatrist, or a mental health expert may diagnose ADHD. To do so, he or she will talk with parents and teachers and watch the child’s behavior. Diagnosis also depends on results from physical, nervous system, and mental health testing. Certain tests may be used to rule out other health problems. Others may check thinking skills and certain skill sets.

How is ADHD treated in children?

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.

Treatment for ADHD may include:

Psychostimulant medicines. These medicines help balance chemicals in the brain. They help the brain to focus and may reduce the major symptoms of ADHD.

Non-stimulant medicines. These can help decrease the symptoms of ADHD and are often used in conjunction with stimulant medicines for even better results.

Behavior management training for parents. Parenting children with ADHD may be hard. It can cause challenges that create stress within the family. Classes in behavior management skills for parents can help lower stress for all family members. This training often happens in a group setting that encourages parent-to-parent support. Behavior management techniques tend to improve targeted behaviors in a child, such as completing school work.

Other treatment. Self-management, education programs, and assistance through your child’s school.

How can I help prevent ADHD in my child?

Experts don’t know how to prevent ADHD in children. But spotting and treating it early can lessen symptoms and enhance your child’s normal development. . It can also improve your child’s quality of life.

How can I help my child live with ADHD?

Here are things you can do to help your child:

Keep all appointments with your child’s healthcare provider.

Talk with your child’s healthcare provider about other providers who will be involved in your child’s care. Your child may get care from a team that may include counselors, therapists, social workers, psychologists, school psychologists, school counselors, teachers, and psychiatrists. Your child’s care team will depend on your child’s needs and how serious the ADHD is.

Adhere to behavioral and educational treatment plans. Work with your team to adjust the plan if it's not working.

Give medicines as prescribed

Tell others about your child’s ADHD. Work with your child’s healthcare provider and schools to develop a treatment plan.

Reach out for support from local community services. ADHD can be stressful. Being in touch with other parents who have a child ADHD may be helpful.

Key points about ADHD in children

ADHD is a behavior disorder. It's often first diagnosed in childhood.

There are 3 major types. They are based on a child’s symptoms.

A child with ADHD may have trouble paying attention. He or she may also be impulsive and hyperactive.

The cause of ADHD may be genetic. It tends to run in families.

A healthcare provider diagnoses ADHD after observing a child’s behavior and doing certain tests.

Treatment often includes medicine. Parents may also get training in behavior management skills. Your child may also be able to take self-management training at school.

Tips to help you get the most from a visit to your child’s healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child’s condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

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ADHD diagnoses are rising. 1 in 9 U.S. kids have gotten one, new study finds

Maria Godoy

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopment disorders among children. SIphotography/Getty Images hide caption

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopment disorders among children.

About 1 in 9 children in the U.S., between the ages of 3 and 17, have been diagnosed with ADHD. That's according to a new report from the Centers for Disease Control and Prevention that calls attention-deficit/hyperactivity disorder an "expanding public health concern."

Researchers found that in 2022, 7.1 million kids and adolescents in the U.S. had received an ADHD diagnosis – a million more children than in 2016. That jump in diagnoses was not surprising, given that the data was collected during the pandemic, says Melissa Danielson, a statistician with the CDC's National Center on Birth Defects and Developmental Disabilities and the study's lead author.

She notes that other studies have found that many children experienced heightened stress, depression and anxiety during the pandemic. "A lot of those diagnoses... might have been the result of a child being assessed for a different diagnosis, something like anxiety or depression, and their clinician identifying that the child also had ADHD," Danielson says.

The increase in diagnoses also comes amid growing awareness of ADHD — and the different ways that it can manifest in children. Danielson says that may help explain why girls are becoming more commonly diagnosed with ADHD compared to boys than they had been in the past. She says boys have long been diagnosed with ADHD at around two and half times the rate of girls, but the new reports finds that difference is narrowing.

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Decades ago, ADHD was thought of as a disorder of hyperactivity among boys, Danielson says. "Boys will often have hyperactive or impulsive ADHD, where they'll run into the street or jump off things or do things that might make them more likely to be injured," she says.

"Girls tend to manifest their ADHD in a more inattentive way. They'll be daydreaming or have a lack of focus or be hyper focused on a particular task that maybe is not the task that they need to be focused on," says Danielson.

The study, which appears in the Journal of Clinical Child & Adolescent Psychology, was based on data from the National Survey of Children's Health , which gathers detailed information from parents.

While the report found that the number of kids diagnosed with ADHD had risen since 2016, only about half of them were taking medication to treat the condition – compared with two-thirds of children back in 2016. The data didn't look into reasons why this might be, but Danielson notes that reports of shortages of ADHD medications began around the time the data was collected.

Dr. Max Wiznitzer, a professor of pediatric neurology at Case Western Reserve University, says he suspects some parents may be reluctant to put their kids on ADHD medication out of misguided concerns. "There's the myth that it's addictive, which it's not." He says studies have shown people treated with ADHD have no increased risk of drug abuse.

Want to protect your kids' eyes from myopia? Get them to play outside

Wiznitzer says medication is important because it can help kids focus by controlling symptoms of impulsivity, overactivity and inattention. But ADHD treatment also requires therapy that can teach children — and their parents — behavioral and educational strategies to manage their condition. "It's always a two-pronged approach," he says. He finds it troubling that the report found less than half of kids and adolescents diagnosed with ADHD were getting any behavioral therapy.

The report also found that nearly 78% percent of children diagnosed with ADHD had at least one other diagnosed disorder. The most common were behavioral or conduct problems, anxiety and developmental delays. Autism and depression were also frequently observed, Danielson says.

Kids with ADHD are at increased risk for other conditions including depression, anxiety and substance abuse and if left untreated, ADHD can raise the risk of serious health concerns in adulthood. This includes a higher risk of diabetes, heart disease and shortened life span, Wiznitzer says – which is why increased awareness and diagnosis is important.

Danielson says parents can also find information on treatment and services at CHADD — Children And Adults with ADHD , a non-profit resources organization where Wiznitzer serves on the advisory board.

He says parents seeking treatment for their kids should start with a conversation with their pediatrician.

This story was edited by Jane Greenhalgh.

• attention-deficit/hyperactivity disorder (ADHD)
• kids health

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Understanding ADHD from a Biopsychosocial-Cultural Framework: A Case Study

• Published: 15 October 2014
• Volume 19 , pages 54–62, ( 2015 )

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The biopsychosocial-cultural framework is a systemic and multifaceted approach to assessment and intervention that takes into account biological, psychological, and socio-cultural factors that influence human functioning and service delivery. Although originally developed to assess physical health and medical illness, this contemporary model can be used as a framework for school psychologists to address the mental health needs of culturally and linguistically diverse youth with Attention-Deficit/Hyperactivity Disorder (ADHD). School psychologists can apply this model when conceptualizing academic, behavioral, and social-emotional functioning of children and adolescents, while also considering cultural barriers relating to treatment acceptability when working with families. Because it encourages school psychologists to address presenting problems in a culturally sensitive and contextual manner, this model may reduce bias and result in more equitable mental health outcomes. The purpose of this article is to discuss the biopsychosocial-cultural model, its advantages and disadvantages, and its application in a case study of a Hispanic child with ADHD.

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Culturally Responsive Approaches for Addressing ADHD Within Multi-tiered Systems of Support

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Pham, A.V. Understanding ADHD from a Biopsychosocial-Cultural Framework: A Case Study. Contemp School Psychol 19 , 54–62 (2015). https://doi.org/10.1007/s40688-014-0038-2

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Evidence-based treatment of attention deficit/hyperactivity disorder in a preschool-age child: a case study

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• 1 Department of Child & Adolescent Psychiatry, New York University Child Study Center, USA.
• PMID: 18470784
• DOI: 10.1080/15374410801955904

This case study illustrates a behavioral treatment of "Peter," a 4-year-old male with attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder. Multiple evidence-based treatment procedures were implemented, affording the opportunity to explore issues common to the clinical application of empirically supported interventions. Among the strategies utilized were behavioral parent training, school consultation and behavioral training of educators, school-based contingency management, and a behavioral daily report card. Numerous issues are discussed, including the limited evidence regarding interventions for preschool-age children with ADHD, factors influencing treatment planning and sequencing, collaboration with schools and parents, and evidence-based assessment of treatment gains.

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Attention-deficit Hyperactivity Disorder (ADHD): Two Case Studies

• Authors: Authors: Joseph Biederman, MD; Stephen V. Faraone, PhD
• THIS ACTIVITY HAS EXPIRED FOR CREDIT

Target Audience and Goal Statement

This activity has been designed to meet the educational needs of pediatricians, family practitioners, child and adolescent psychiatrists, and general psychiatrists involved in the management of patients with ADHD.

Attention-deficit hyperactivity disorder (ADHD) is a chronic condition that affects 8% to 12% of school-aged children and contributes significantly to academic and social impairment. There is currently broad agreement on evidence-based best practices of ADHD identification and diagnosis, therapeutic approach, and monitoring. However, the increasing rate of diagnosis and treatment in the pediatric population has contributed to the significant public debate and misunderstanding of ADHD. Despite increased awareness, Attention-deficit hyperactivity disorder (ADHD) is a chronic condition that affects 8% to 12% of school-aged children and contributes significantly to academic and social impairment. There is currently broad agreement on evidence-based best practices of ADHD identification and diagnosis, therapeutic approach, and monitoring. However, the increasing rate of diagnosis and treatment in the pediatric population has contributed to the significant public debate and misunderstanding of ADHD. Despite increased awareness, ADHD remains underrecognized and may be undertreated by a factor of 10 to 1 in the US population. In order to educate the public and ensure optimal outcomes for ADHD patients, this continuing education activity has been developed to provide physicians and other healthcare providers with the most current information available on assessing and treating ADHD.

Upon completion of this activity, participants should be able to:

• Discuss the incidence of ADHD in adolescents and adults.
• Identify DSM-IV criteria used to make the diagnosis of ADHD in each age group.
• List important comorbidities of ADHD and identify distinguishing features between ADHD and other psychiatric diagnoses with similar manifestations.
• Describe a pharmacologic approach to ADHD treatment, including treatment goals and choice of medication.
• Enumerate self-management skills to be recommended when coaching ADHD patients on how to get along at school, at work, and at home.

Disclosures

Accreditation statements, for physicians.

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). The Postgraduate Institute for Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Postgraduate Institute for Medicine designates this educational activity for a maximum of 1.0 Category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board. This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. Follow these steps to earn CME/CE credit*:

• Read the target audience, learning objectives, and author disclosures.
• Study the educational content online or printed out.
• Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. In addition, you must complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 5 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage. *The credit that you receive is based on your user profile.

Case 2: ADHD in an Adult

Case history.

A 42-year-old woman, mother of a son in his junior year of high school and a 20-year-old daughter, both living at home, comes seeking help because she feels her marriage is falling apart. This patient is the mother of the adolescent with ADHD in the previous case history. Her speech is rambling and a little impulsive. The physician manages to piece together the following history during her first visit, which was scheduled for 30 minutes but takes an hour because of her long, unfocused answers to the questions.

School had always been relatively hard for the patient, starting in grammar school. Though she had presented no behavior problems, teachers consistently complained of the patient's inattention and disorganization. With the help of summer school and tutors she managed to stay on course until she graduated from high school and even to get accepted to college. She was placed on probation after one semester at the university's business school, taking incompletes or "D's" and "F's" in each of her courses because she missed classes. She turned in assignments late, if at all; what she did hand in was sketchy and sloppy. Her advisor recommended that she switch her major from accounting to marketing, taking advantage of the patient's creative streak. With the help of tutoring and coaching in how to stay organized, the patient managed to earn her degree.

She was married for 6 months immediately after high school, but that marriage ended by mutual consent because, the patient says, "Neither of us had any idea what it meant to be in an adult relationship." The patient met her current husband, a graphic arts major, in a college advertising class. They were married in his senior year. It should have been her senior year too, but it took her an extra 1½ years to graduate. After they started dating they dreamed of developing their own business, combining her expertise in marketing with his in design. This was not to be. Not long after they started living together, her husband found that he could not count on his spouse to arrive at a meeting on time, remember to make an important phone call, or even to keep the checkbook in a consistent place. They decided to start a family together instead of a business. The husband worked in advertising while his wife stayed home with their 2 children.

As the children grew they had their own school problems and, later, social and legal troubles. (See previous case.) Their mother did her best to fulfill her role as stay-at-home caretaker, but it still fell on their father to pack their lunches, get them to the bus stop on time, and help them daily with homework. In spite of the patient's background in business, her husband took care of paying bills, balancing the checkbook, and preparing tax returns. The wife became a good cook. Her meals were quite creative but often served late because she had had to run out to the store, sometimes more than once, to purchase ingredients she had forgotten.

Once the children were in third and sixth grade, the patient found employment outside the home. Her husband took it upon himself to create a chore list for each family member. He was the only one to follow through consistently with his assigned tasks. Their home is no less messy than it was when the patient was at home full-time because even then, she was never organized enough to get ahead on the housework. Thanks to the patient, the home is decorated quite creatively. She rearranges the furniture and art work on the walls every few weeks because, she says, keeping things the same for too long makes her feel restless.

The patient's first job was in the marketing department of a local business. Within a few months she lost that position because of tardiness, absenteeism, unmet deadlines, and a general impression that she was not reliable or competent. She made few friends at work except for some smokers with whom she congregated regularly at the back door of the business.

She smokes 2 packs of cigarettes per day, a habit she has had since high school. She also drinks caffeinated coffee all day. The patient has recently cut down on her alcohol consumption after a near-miss on a second DUI and a confrontation with her husband over her escalating alcohol intake. She had tried other recreational drugs in college but did not continue using them after her marriage.

Losing that job as a marketer was the first of a succession of job losses. Subsequent reasons included the undependability shown at her first job, but she also impulsively quit when frustrated with working conditions and blurted out harsh criticism of the boss. Each new job brought lower pay and lower status than the previous one. The patient berates herself for her poor job performance, but though intelligent and educated enough, she can't seem to do any better. At the time of this interview she is working as the person on duty at 2 different laundromats for a 60+-hour work week. She likes how busy and active she is at this job; between servicing customers and machines she rarely sits down.

The home environment is messier and more chaotic than ever. It seems to her family that they are all perpetually being sent about the house in search of her glasses, keys, or wallet.

The patient has little energy for anything but her job. According to records received, her previous primary care doctor thought she might be depressed and tried a selective serotonin reuptake inhibitor, with little relief. The patient's answer to a direct question about whether she had taken the medication regularly is vague. It is not clear whether she did not trust the diagnosis of depression or could not remember to take her pills regularly, but the physician suspects that the patient did not have an adequate therapeutic trial of antidepressants. Progress notes in the previous doctor's record confirm the suspicion of noncompliance. That physician also tried clonidine, Vitamin B 6 , and various other measures without success to alleviate the severe PMS symptoms that had escalated over recent years. Still, she sleeps well and maintains a good appetite.

The patient describes herself as unpredictably irritable. She admits to picking fights with her husband and says she has completely lost interest in sex. Now, with concerns looming about both of their children compounded by the patient's being away from home so much of the time, her husband has threatened to leave. She feels like a failure in all realms: as a mother, a spouse, a homemaker, and a breadwinner.

Cathleen Rui Lin Lau Case Manager, Twinkle Intervention Center , Singapore

Guo Hui Xie EdD, Board-Certified Educational Therapist Special Needs Consultancy & Services, Singapore

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A CASE STUDY OF A CHILD WITH ATTENTION DEFICIT/HYPERACIVITY DISORDER (ADHD) AND MATHEMATICS LEARNING DIFFICULTY (MLD)

This is a case study of a male child, EE, aged 8+ years, who was described as rather disruptive in class during lesson. For past years, his parents, preschool and primary school teachers noted his challenging behavior and also complained that the child showed a strong dislike for mathematics and Chinese language – both are examinable academic subjects. As a result of the disturbing condition, EE was referred to an educational therapist at a private intervention center for a diagnostic assessment. The child was identified with Attention Deficit-Hyperactivity Disorder (ADHD)-Combined subtype. This aim of this paper is to discuss about the effects of ADHD on mathematics learning and how to avoid misdiagnosis or over-diagnosis of a behavioral-cum-learning disorder.

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A CASE STUDY

Observations of a student with ADHD over a 3-week time span. 

Student X is a 14 year-old male in a 9 th  Grade English class. He is average height and build. He has no physical disabilities, but suffers from a mental disorder – ADHD. He often makes careless mistakes in schoolwork. He does not pay attention to detail. He has trouble staying focused while reading long texts. He also has difficulty staying still during a lecture. He fidgets and shakes his legs uncontrollably when seemingly annoyed or anxious. He has trouble turning in homework on time and meeting deadlines in general. He frequently does not respond when spoken to directly and appears to be distracted even though he is performing no obvious task. He lets his mind wander and appears to daydream often. When he does respond and participate, he is usually off topic. Overall, he appears uninterested and aloof. One might say that the behavior is defiant – a consciously overt reluctance to participate in school. However, this student has been diagnosed by a physician as being ADHD. He has an involuntary learning disability which requires support, therapy, social skills training and/or medication.  

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Educating children with ADHD is no easy task. Know that you are not alone. Please enlist the help of our school to find the right plan and solution for your child.

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• Published: 22 August 2024

Child maltreatment as a transdiagnostic risk factor for the externalizing dimension: a Mendelian randomization study

• Julian Konzok   ORCID: orcid.org/0000-0002-4232-4105 1 ,
• Mathias Gorski   ORCID: orcid.org/0000-0002-9103-5860 2 ,
• Thomas W. Winkler   ORCID: orcid.org/0000-0003-0292-5421 2 ,
• Sebastian E. Baumeister 3 ,
• Varun Warrier   ORCID: orcid.org/0000-0003-4532-8571 4 ,
• Michael F. Leitzmann 1 &
• Hansjörg Baurecht 1  

Molecular Psychiatry ( 2024 ) Cite this article

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• Psychiatric disorders

Observational studies suggest that child maltreatment increases the risk of externalizing spectrum disorders such as attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), antisocial personality disorder (ASPD), and substance use disorder (SUD). Yet, only few of such associations have been investigated by approaches that provide strong evidence for causation, such as Mendelian Randomization (MR). Establishing causal inference is essential given the growing recognition of gene-environment correlations, which can confound observational research in the context of childhood maltreatment. Evaluating causality between child maltreatment and the externalizing phenotypes, we used genome-wide association study (GWAS) summary data for child maltreatment (143,473 participants), ADHD (20,183 cases; 35,191 controls), CD (451 cases; 256,859 controls), ASPD (381 cases; 252,877 controls), alcohol use disorder (AUD; 13,422 cases; 244,533 controls), opioid use disorder (OUD; 775 cases; 255,921 controls), and cannabinoid use disorder (CUD; 14,080 cases; 343,726 controls). We also generated a latent variable ‘common externalizing factor’ (EXT) using genomic structural equation modeling. Genetically predicted childhood maltreatment was consistently associated with ADHD (odds ratio [ OR ], 10.09; 95%-CI, 4.76–21.40; P  = 1.63 × 10 −09 ), AUD ( OR , 3.72; 95%-CI, 1.85–7.52; P  = 2.42 × 10 −04 ), and the EXT ( OR , 2.64; 95%-CI, 1.52–4.60; P  = 5.80 × 10 −04 ) across the different analyses and pleiotropy-robust methods. A subsequent GWAS on childhood maltreatment and the externalizing dimension from Externalizing Consortium (EXT-CON) confirmed these results. Two of the top five genes with the strongest associations in EXT GWAS, CADM2 and SEMA6D, are also ranked among the top 10 in the EXT-CON. The present results confirm the existence of a common externalizing factor and an increasing vulnerability caused by child maltreatment, with crucial implications for prevention. However, the partly diverging results also indicate that specific influences impact individual phenotypes separately.

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Introduction.

Several lines of research indicate high comorbidity among externalizing psychopathologies and significant heritability of a common externalizing factor [ 1 , 2 ]. This common externalizing factor encompasses disinhibition, impulsivity, antisocial-aggressive behavior as well as substance (ab)use [ 1 ]. Clinically, the externalizing spectrum comprises attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), antisocial personality disorder (ASPD), and substance use disorders (SUD) [ 3 ]. Multiple studies have demonstrated a shared genetic basis for these disorders [ 4 , 5 ].

One of the main candidates influencing the etiology of psychiatric disorders is childhood maltreatment. Childhood maltreatment encompasses emotional, sexual, physical abuse, and emotional and physical neglect [ 6 ]. A wide range of observational studies, including case-control designs, showed that childhood maltreatment increases risks for ADHD [ 7 ], ASPD [ 8 ] and SUD [ 9 ]. Twin and family studies demonstrated that childhood maltreatment has a heritability of 6 to 62% [ 10 , 11 ], depending on the subtype. These findings appear surprising, given that childhood maltreatment is an environmental, and thus potentially modifiable, determinant. However, investigations have shown that such heritability is derived from gene-environment correlations (rGE) with passive (i.e., family environment influenced by shared genetic factors of parents and infants), evocative/ reactive (i.e., parental style partly caused by hereditary characteristics of the offspring), and active (i.e., selection of specific contexts influenced by heritable traits) subtypes [ 12 ] (see Fig.  1 ). This raises the question of whether the relationship between childhood maltreatment and externalizing disorders is causal or is mainly driven by rGE. In the second case, risk for psychiatric diseases will only slightly be modified by childhood maltreatment, with crucial implications for prevention and treatment. Besides experimental and quasi-experimental designs controlling for genetic confounding, Mendelian Randomization (MR) [ 13 ] can be used to assess causal effects of environmental risk factors on mental health outcomes under certain key assumptions, even in the presence of rGE [ 14 ]. However, in the presence of rGE, particular attention should be paid to methods (e.g., Causal analysis using summary effect estimates, CAUSE) [ 15 ] reducing bias (e.g., correlated pleiotropy) arising from genetic correlation [ 14 , 16 ]. Correlated pleiotropy occurs when genetic variants influence both exposure and outcome through a heritable shared factor (see Fig.  1 ), which can bias MR analysis.

In evocative/active rGE ( A ), connection between child genotypes and exposure is conditioned on child behavior potentially resulting in a pathway to the outcome independent of the exposure. In passive rGE ( B ), causal estimation could be confounded by parent genotype. Dashed arrows symbolize potential confounding or pleiotropic pathways, solid arrows represent causal pathways.

To the best of our knowledge, only one two-sample MR study investigated the effect of childhood maltreatment on ADHD indicating an increasing risk [ 12 ]. Evidence from MR studies for other externalizing disorders (e.g., ASPD, SUD) is sparse. Furthermore, observational studies suggest an effect of externalizing problems on the risk of childhood maltreatment [ 7 ], which so far has only been investigated in ADHD patients using an MR approach. Additionally, no investigation has examined the externalizing factor reflecting common variation across externalizing disorders and a shared genetic basis. Evidence for childhood maltreatment as a transdiagnostic risk factor would have crucial implications for prevention strategies and programs (e.g., target individuals).

The current study aimed at investigating the causal relationship between childhood maltreatment and the risk of externalizing disorders accounting for rGE. In addition, we were interested in examining whether such a relationship also exists for a common externalizing factor reflecting comorbidity and continuity of externalizing disorders over the lifespan.

Materials and methods

Single-nucleotide polymorphisms (SNPs) were used as instrumental variables (IVs) to estimate the effect of the exposure on the outcomes unbiased from any unobserved confounding under the condition of valid IVs. IVs are valid if the following three assumptions are fulfilled. (i) The genetic variant is associated with the exposure (relevance assumption), (ii) the variant-outcome association is independent of a potential confounder (exchangeability assumption) and (iii) the genetic variant influences the outcome exclusively through the exposure, independent of any horizontal pleiotropy i.e., independent of any confounder or direct effect (exclusion restriction). Furthermore, several complementary analyses were conducted to evaluate potential biasing effects of correlated and uncorrelated horizontal pleiotropy as well as reverse causation [ 13 , 17 ].

Selection of instrumental variables for childhood maltreatment

Linkage-disequilibrium-(LD)-independent SNPs associated with childhood maltreatment were selected from a GWAS in 143,473 participants [ 12 ] (exclusively from UK Biobank to avoid overlap with the outcome GWAS) (Supplementary Table  S1 ) at a genome-wide level of significance ( P value < 5 × 10 −8 ). Within this clumping algorithm, we excluded SNPs that exhibited strand ambiguity and had a minor allele frequency of less than 0.01. We applied a threshold of r 2 at 0.001 and employed a window size of 10 Mb. Then, we calculated the F -statistic and the proportion of the variance explained by childhood maltreatment by summarizing values from all SNPs. In the UK Biobank, participants completed the five-item Childhood Trauma Screener [ 18 ], which is a retrospective assessment. This screener includes one question for each of the five trauma subtypes (emotional, sexual, and physical abuse, and emotional and physical neglect), with responses ranging from 0 (never true) to 4 (very often true), resulting in total scores ranging from 0 to 20. The continuously coded total score was included in the GWAS for childhood maltreatment. In the original study, the authors identified 16 significant SNPs associated with 9 genomic risk loci [ 12 ] for the UK Biobank only data set.

Genome-wide association study summary statistics for the six externalizing disorders

To maintain consistency in the used phenotype definitions, we focused on GWAS for externalizing disorders clinically diagnosed by ICD or DSM, resulting in partly diminished numbers of cases due to limited data availability. For ADHD, we used data from a meta-analysis of samples of the Psychiatric Genomics Consortium (PGC) and the iPSYCH project totaling 20,183 cases and 35,191 controls [ 19 ]. For CD and ASPD, GWAS summary statistics stemmed from the FinnGen Consortium with 451 cases and 256,859 controls and 381 cases and 252,877 controls, respectively [ 20 ]. The GWAS on AUD and OUD were also conducted by the FinnGen Consortium with 13,422 cases and 244,533 controls and 775 cases and 255,921 controls, respectively [ 20 ]. Summary data statistics for cannabinoid use disorder (CUD) were derived from the PGC Substance Use Disorders working group, iPSYCH, and deCODE, with 14,080 cases and 343,726 controls [ 21 ] (Supplementary Table  S1 , S2 ). Manhattan and quantil-quantil (Q-Q) plots of the used GWAS summary data are depicted in Supplementary Fig.  S3 , S4 .

Statistical analyses

Shared genetic basis of the externalizing phenotypes: the externalizing factor (ext).

Using GenomicSEM, a common factor model and a commonfactorGWAS function were performed with a diagonally weighted least squares (DWLS) estimation, integrating the GWAS of the six externalizing phenotypes to a common factor GWAS. We assessed the model fit using the comparative fit index (CFI), standardized root mean square residual (SRMR), and the standardized loading of the common externalizing factor on the specific phenotypes. CFI scores of ≥0.90 indicate adequate fit, while values of ≥0.95 imply a good model fit [ 22 ]. SRMR values below 0.10 suggest an adequate model fit, values less than 0.05 point to a good fit [ 23 ]. SNPs with a significant heterogeneity test ( P  < 0.05) were excluded from the common factor GWAS, and the effective sample size estimation was conducted with a minor allele frequency between 0.4 and 0.1. In the following MR analyses, this more holistic phenotype was termed ‘externalizing factor’ (EXT). To determine the individual importance of each externalizing disorder in shaping the overall EXT, we stepwise excluded each externalizing disorder and correlated these models in a leave-one-out-analysis. Additionally, heterogeneity analysis was applied using Q SNP statistic to test whether each SNP-externalizing-disorder association is conditioned on the common EXT. A significant Q SNP heterogeneity statistic indicated a pathway from the genetic variant to the externalizing disorder, independent of the common EXT.

To identify independent significant SNPs and corresponding genomic risk loci associated with the EXT, we used Functional Mapping and Annotation (FUMA) [ 24 ]. Within Multi-marker Analysis of GenoMic Annotation (MAGMA) gene-based association analysis, genome-wide significant SNPs were initially mapped to 19,176 protein-coding genes, and the SNPs within each gene were collectively tested for their association with EXT. Significance threshold for this analysis was Bonferroni corrected and defined at 2.61 × 10 −6 .

Primary analysis

Power analyses were performed following Brion et al. [ 25 ] (for detailed information see Supplementary Material  1 ). In MR analysis, Wald ratios (i.e. ratio of coefficients method) were calculated by dividing the logistic regression coefficient of the SNP-outcome associations by the regression coefficient of the SNP-exposure associations for each genetic variant selected from exposure GWAS. The delta method was used for standard error calculation. The ratio estimates (presumed to be linear on the log odds ratio scale) were subsequently combined using a multiplicative random effects model in an inverse variance weighted estimate (IVW) over all SNPs. The odds ratio is obtained by using the ratio estimates as exponent to the basis e [ 13 , 17 ]. We used a false-discovery rate (FDR) corrected threshold of .05 ( q -value) to account for multiple testing.

Sensitivity analysis: test for directional pleiotropy and pleiotropy-robust methods

For outlier diagnostics indicating invalid instruments (violation of the exclusion restriction assumption), the Q and I² statistic were used to test globally for heterogeneity. Additionally, leave-one out analysis was conducted to check whether the overall estimate was driven by a specific SNP. Furthermore, the MR Egger intercept test was conducted to evaluate potential influences of directional pleiotropic effects (i.e., the average pleiotropic effect deviates from zero and is shifted in one direction). Weighted median, radial regression MR, and MR pleiotropy residual sum and outlier (MR PRESSO) [ 26 ] were conducted as pleiotropy-robust methods.

Causal analysis using summary effect estimates (CAUSE) and test for reverse causation

Facing the low effective sample size in some summary statistics, we employed Causal Analysis Using Summary Effect estimates (CAUSE) that uses all genetic variants for causal estimation, thereby increasing statistical power [ 15 ]. CAUSE aims to distinguish between a causal effect of the exposure on the outcome (i.e., correlation of between all SNP-exposure and SNP-outcome estimates of all genetic variants associated with the exposure) from correlated pleiotropy induced by a shared (unknown) factor (i.e., correlation only in a subset of variants). Causal inference was obtained by a Bayesian approach comparing the two nested models, the causal model allowing a nonzero causal effect and the sharing model with causal effect fixed at zero [ 15 ].

Reverse causation analysis, i.e. exposure and outcome were swapped, was also carried out by CAUSE due to the low number of genetic instruments and effective sample size in some outcome GWAS.

Replication analysis

As replication analysis, we used SNPs from a second childhood maltreatment GWAS of 15,651 individuals of European descent from the Avon Longitudinal Study of Parents and Children (ALSPAC) [ 27 ], Adolescent Brain Cognitive Development Study (ABCD) [ 28 ], and Generation R [ 29 ] recording childhood maltreatment prospectively using multiple questionnaires at multiple instances (majority parent report, several self-report) [ 12 ]. Since this GWAS for childhood maltreatment is also of limited statistical power, we again employed the CAUSE approach which increases power by incorporating all genetic variants.

In addition, we rerun the primary analysis replacing the estimated EXT by the externalizing factor obtained from a GWAS conducted by the Externalizing Consortium (EXT-CON) excluding 23andme [ 5 , 30 ] with 579 genome-wide significant SNPs. These SEM-GWAS employed a broader definition of externalizing traits for inclusion and did not limit their analysis solely to ICD-coded disorders.

All analyses were performed using the packages MRInstruments (0.3.2), MendelianRandomization (0.6.0), TwoSampleMR (0.5.6), MRPRESSO (1.0) and cause (1.2.0) in R, version 4.2.2 (2022/10/31). We report the methods and results following the STROBE-MR (Strengthening the Reporting of Observational studies in Epidemiology – Mendelian randomization) statement [ 31 ].

The common factor model exhibited a CFI of 1 and a SRMR of 0.097, indicating a good model fit (CFI > 0.95, SRMR < 0.10). All indicators showed standardized loadings on the EXT over 0.60, with strong loadings for AUD (0.84, SE  = 0.05, p  = 2.31 × 10 −54 ) and CUD (0.82, SE  = 0.06, p = 2.57 × 10 −40 ), moderate loadings for ADHD (0.63, SE  = 0.05, p  = 1.29 × 10 −31 ), CD (0.74, SE  = 0.06, p  = 2.37 × 10 −13 ), ASPD (0.77, SE  = 0.09, p  = 2.31 × 10 −54 ), and OUD (0.75, SE  = 0.11, p  = 1.15 × 10 −12 ) (see Fig.  2 ). The Supplementary Fig.  S1 depicts the genetic correlation matrix of the indicator GWAS. The EXT explained 39.2% of the variance of ADHD, 54.6% of CD, 58.6% of ASPD, 69.7% of AUD, 57.0% of OUD, and 66.9% of CUD. The chi-squared-test yielded a non-significant result (χ 2 ( df  = 9) = 6.91, P  = 0.65), indicating a better fit for the common model to the observed GWAS data. This also confirmed the existence of a shared genetic basis of the six externalizing phenotypes. Q SNP analysis identified four SNPs displaying remarkable heterogeneity ( P  < 5 × 10 −08 ), but only one overlapped with the genome-wide significant variants associated with the EXT, indicating no pleiotropic effect among individual externalizing disorders, independent of the common EXT. After excluding SNPs with a significant heterogeneity test ( P  < 0.05), the common GWAS comprised 6,004,696 SNPs associated with the EXT. Each individual externalizing disorders notably contributed to the EXT, as evidenced by comparable correlation between the different leave-one-out models ( r g : 0.90–0.99, SE: 0.01–0.17). The common factor GWAS exhibited 45 independent genome-wide significant genetic variants with 39 genomic risk loci. Figure  3 illustrates the top 10 genes with the strongest associations (see also Supplementary Table  S3 ). The top five genes include forkhead box P2 (FOXP2), cell adhesion molecule 2 (CADM2), glutamate ionotropic receptor delta type subunit 2 (GRID2), bassoon presynaptic cytomatrix protein (BSN), and semaphoring 6D (SEMA6D). These genes were previously associated among others with externalizing disorders and other psychiatric [ 32 , 33 ] as well as addiction related traits [ 34 , 35 ].

The rectangles symbolize the indicators, the latent common factor is presented as circle. Single headed arrows indicate the direction of the regression effect with the standardized loadings. Double headed arrows reflect standardized residuals.

The 10 significant genes with the strongest association are labeled. The red dashed line indicates Bonferroni corrected significance threshold at 2.61 × 10 −6 .

Power analysis

The analysis had a power of ≥90% to detect a minimum OR of 2.00 for ADHD, 5.00 for CD, >5.00 for ASPD, 1.80 for AUD, 4.00 for OUD, and 1.80 for CUD (Supplementary Table  S4 ).

The 6 selected genetic instruments explained 0.2% of the variability of the exposure, with a minimum F -statistic of 29.85 (Supplementary Table  S5 ). The Standard IVW MR analysis showed significant effects corrected for multiple testing of childhood maltreatment on ADHD, AUD and the EXT. The effects of childhood maltreatment on CD, ASPD, OUD and CUD did not reach statistical significance (see Fig.  4 and Supplementary Table  S6 ).

CI confidence interval, OR odds ratio, P  =  p value, q = adjusted p values using a FDR approach.

For CUD and the EXT, we observed heterogeneity between the Wald ratios of the IVW estimates suggesting pleiotropy. However, the MR Egger intercept test indicated no directional pleiotropy for both outcomes (Supplementary Table  S7 ). Visual inspection of funnel plots (Supplementary Fig.  S2 ) supported these findings and showed no strong deviation from symmetrical distributions, indicating balanced rather than directional pleiotropy and does not distort causal estimation. The applied random effects IVW model accounts for additional heterogeneity. Consistent with this, pleiotropy-robust methods (weighted median, radial regression MR, and MR PRESSO) showed similar results to the random effects IVW for all phenotypes (Supplementary Table  S6 ). Additionally, the stepwise leave-one-out analysis did not reveal any genetic variant as a leverage point with high influence (see Supplementary Table  S8 ).

The CAUSE approach confirmed the significant causal associations of childhood maltreatment with ADHD ( OR  = 1.90, 95% credible interval ( CredIn ): 1.23–2.91, P  = 0.004), ASPD ( OR  = 9.12, 95% CredIn : 1.07–79.04; P  = 0.045), and the EXT ( OR  = 1.34, 95% CredIn : 1.14–1.67; P  = 1.43 × 10 −07 ). However, there was no significant difference between the causal and shared model for CD ( OR  = 3.94, 95% CredIn : 0.56–25.79; P  = 0.153), AUD ( OR  = 1.35, 95% CredIn : 0.84–2.14; P  = 0.201), OUD ( OR  = 2.41, 95% CredIn : 0.51–11.14; P  = 0.260), and CUD ( OR  = 2.36, 95% CredIn : 0.87–1.42; P  = 0.179) suggesting no causal association of child maltreatment on those traits.

Reverse causation analyses suggested only a significant causal influence of ADHD ( OR  = 1.01, 95% CredIn : 1.00–1.02, P  = 8.85 × 10 −05 ) on childhood maltreatment with estimates close to one, but not for CD ( OR  = 1.01, 95% CredIn : 0.99–1.04, p  = 0.514), ASPD ( OR  = 1.01, 95% CredIn : 0.99–1.03, P  = 0.327), AUD ( OR  = 1.02, 95% CredIn: 0.99–1.04, P  = 0.050), OUD ( OR  = 1.00, 95% CredIn: 0.98–1.02, P  = 1.00), CUD ( OR  = 1.00, 95% CredIn: 0.98–1.02, P  = 1.00), and the EXT ( OR  = 1.01, 95% CredIn: 0.99–1.04, P  = 0.514).

Analysis using an independent childhood maltreatment GWAS replicates only the finding of a causal effect of childhood maltreatment on the EXT ( OR  = 1.31, 95% CredIn : 1.04–1.64, P  = 0.021), but not on ADHD and AUD. The null association with all other externalizing disorders was confirmed (Supplementary Table  S9 ).

In a second replication we replaced the summary statistics of the calculated EXT by the EXT-CON [ 5 , 30 ]. Again, genetically predicted childhood maltreatment is causally associated with the EXT-CON (1.69, 95% CI : 1.30–2.21, p  = 8.83 × 10 −05 ).

The current study investigated the causal association between childhood maltreatment and the risk for externalizing disorders such as ADHD, CD, ASPD, and substance use disorders such as AUD, OUD and CUD. Genetically predicted childhood maltreatment strongly increased the risk for ADHD, and AUD in later life, aligning with previous observational studies of ADHD [ 7 ] and alcohol use disorder patients [ 36 ]. In contrast to observational methods, MR methods have the advantage of effectively accounting for effects of unobserved confounding factors. This point is important to emphasize, as there are other potential (confounding) factors (e.g., socioeconomic status, rGE) that contribute to both childhood maltreatment and mental disorders. Furthermore, the causal effect of childhood maltreatment on externalizing disorders is supported by animal studies that infer causality through experiments that are ethically unacceptable in humans. These studies demonstrated that early childhood stress influences alcohol and drug consumption and other behavioral differences in monkeys and rodents [ 37 , 38 ].

We found no causal effect of childhood maltreatment on the risk for development of CD, ASPD, OUD, and CUD. It is important to note that GWAS for CD, ASPD and OUD exhibited a rather small proportion of cases compared to controls, which led to limited power to detect differences. Thus, we performed the CAUSE approach using all genetic variants for causal estimation, thereby increasing statistical power. Using CAUSE, childhood maltreatment is besides ADHD and AUD also causally related with ASPD. However, this causal relation was not identified by IVW analysis, which may be due to low power. Further research using GWAS with a larger effective sample size is needed for clarification.

The main methodological challenge in the presence of rGE is pleiotropy, which can lead to an inaccurate causal estimation. MR PRESSO and MR egger rely on the InSIDE assumption (i.e., pleiotropic effect has to be independent of the instrument strength). Both methods can deal with horizontal pleiotropy (i.e., independent genetic effects on exposure and outcome), but not correlated pleiotropy (i.e., variants influence exposure and outcome through shared genetic factor) induced by rGE [ 26 , 39 ]. Median based estimations are robust to all forms of pleiotropy, albeit to a lesser extent. In contrast, the CAUSE approach distinguishes the causal effect of uncorrelated and correlated pleiotropy induced by rGE [ 15 ]. Across the different pleiotropy-robust methods, including CAUSE, childhood maltreatment was consistently associated with risk for the EXT, confirming a causal effect despite rGE. While CAUSE models a single unobserved factor to account for shared and correlated effects, other approaches directly incorporate family and sibling data to control for biasing family effects [ 40 ]. Since we did not have access to parental genotypic data, we were unable to perform within-family MR. Future studies should aim to replicate our findings using within-family designs to further validate the results.

Our analyses also indicated reverse causation between childhood maltreatment and ADHD. This is consistent with a previous MR using partially overlapping data sources [ 12 ]. Not surprisingly, externalizing behavior and temperament are associated with inadequate parental response, which, along with certain other factors (e.g., low parental self control, socioeconomic status), may promote maladaptive parent-child interactions and childhood maltreatment. To date, only a few observational and MR studies have shown this finding [ 7 , 12 ].

Our study demonstrated for the first time that childhood maltreatment leads to a significant susceptibility to the common EXT. This result was also confirmed with the common factor GWAS from the Externalizing Consortium (EXT-CON) [ 5 , 30 ]. Of note, two of the top five genes associated with EXT in our study (CADM2, SEMA6D) also ranked among the top 10 in the EXT-CON GWAS. In contrast to the EXT-CON model, we incorporated also antisocial traits into our EXT model, a well-established facet of the externalizing dimension in various research lines [ 1 , 2 ]. MR analyses of both independent datasets revealed a robust causal relationship, however with divergent odds ratios, possibly attributed to the limited number of genetic instruments due to small sample size. Previous research supports the notion of a highly heritable externalizing factor ( h 2 : 81–84%) [ 1 , 2 ] underlying externalizing phenotypes. Our structural equation modeling revealed a substantial unexplained variance in specific phenotypes, indicating additional factors (i.e., what distinguishes ADHD from ASPD). This is in line with the hierarchical model of the externalizing spectrum [ 1 , 2 ], positing the existence of both general and specific etiological factors. Furthermore, the divergent effect estimates for different disorders in our study also suggest the existence of additional specific factors contributing to the manifestation of individual disorders.

Moreover, when regarding childhood maltreatment as a comprehensive risk factor, it raises the possibility that it might also play a role in increasing susceptibility within the internalizing dimension, such as depression and anxiety. We plan to investigate this aspect in an upcoming study, where we will assess the impact on both the externalizing and internalizing dimensions.

Our study has several limitations. Firstly, the genetic variants we selected explained only a small fraction of the overall variance in childhood maltreatment. Consequently, the GWAS for childhood maltreatment revealed a relatively low number of genome-wide significant SNPs as instruments for MR analyses. Nonetheless, our chosen instruments demonstrated a minimum F-statistic of 29.85, which indicates no evidence of weak instrument bias, reinforcing the reliability of our selected instruments. Furthermore, the complementary CAUSE approach utilizes all available genetic variants, enhancing statistical power. Secondly, as previously mentioned, the statistical power of specific analyses, particularly those related to CD, ASPD, and OUD, was constrained by the relatively small number of cases falling below 1000. However, the incorporation of the complementary CAUSE approach allowed us to generate better powered causal estimates, thereby reducing the false-positive rate. Thirdly, despite exclusively including GWAS on ICD-coded outcomes, it’s possible that variation in measurement methods existed across the different cohorts.

The current study demonstrated that childhood maltreatment ranks among the etiological influences of the common externalizing factor, besides the existence of factors contributing to the specific phenotypes separately. This has crucial implications for prevention strategies. First, it underlines the importance of primary and secondary prevention services, as childhood maltreatment has now been established as a vulnerability factor for numerous psychiatric conditions. Second, our findings support the use of a comprehensive understanding of externalizing disorders in the development of tertiary prevention services for childhood maltreatment, regardless of the onset of externalizing disorders. For instance, interventions could focus on negative emotionality, low fearfulness and effortful control [ 41 ] or target the biological changes (e.g., altered cortisol reactivity), also associated with early stages of the externalizing spectrum [ 42 ].

Data availability

GWAS summary statistics for attention deficit hyperactivity disorder and cannabinoid use disorder from the Psychiatric Genomics Consortium are available at https://pgc.unc.edu/for-researchers/download-results/ , for conduct disorder, antisocial personality disorder, alcohol use disorder, opioid use disorder from the FinnGen Consortium at https://www.finngen.fi/en/access_results/ . The R code is available from the corresponding author on request.

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Acknowledgements

We assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human participants were approved by the committee in the original studies. Written informed consent was obtained from all participants in the original studies. Additionally, we want to acknowledge the participants and investigators of the FinnGen study.

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JK and HB designed the study. JK, HB, TWW, MG, VW and SEB performed the analysis. JK drafted the manuscript. SEB, TWW, MG, VW, MFL and HB provided editorial revisions and suggestions.

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Konzok, J., Gorski, M., Winkler, T.W. et al. Child maltreatment as a transdiagnostic risk factor for the externalizing dimension: a Mendelian randomization study. Mol Psychiatry (2024). https://doi.org/10.1038/s41380-024-02700-8

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Understanding the Struggles of Teens with ADHD

Adhd: the chaos of racing thoughts and broken promises..

Posted August 26, 2024 | Reviewed by Kaja Perina

• What Is ADHD?
• Take our ADHD Test
• Find counselling to overcome ADHD
• Teens with ADHD often struggle with racing thoughts and procrastination, leading to late homework.
• A rigid schedule is essential for teens with ADHD to manage time and stay on track academically.
• An executive functioning coach offers tailored strategies to boost organization and time management.
• Parents must enforce schedules and support teens, recognizing ADHD as the root, not lack of effort.

Parenting a teenager with ADHD includes unique challenges, particularly when it comes to helping them stay organized with their schoolwork. If your child frequently struggles with completing homework on time or turning it in once it's done, you're not alone. This issue is common among teens with ADHD, who often find themselves trapped in a cycle of racing thoughts and procrastination . They may tell themselves that they will get to their homework later, but "later" never seems to come. This pattern can lead to academic difficulties, increased stress , and feelings of failure for both the teen and the parents, who want nothing more than to see their child succeed.

ADHD is not just about being hyperactive or easily distracted; it's about how the brain processes and manages tasks. For adolescents, schoolwork becomes a battleground where their struggles with attention , focus, and organization play out daily. The pressure to keep up with assignments can be overwhelming, and when racing thoughts take over, they quickly lose track of what needs to be done. Despite their best intentions, they often find themselves caught in a loop of delaying tasks, promising to do them later, and then feeling frustrated when they can't follow through.

The Burden of Racing Thoughts

One of the most challenging aspects of ADHD is the relentless nature of racing thoughts. For a teenager, this can mean a constant stream of ideas, worries, and distractions running through their mind. Regarding schoolwork, these thoughts can be both a blessing and a curse. On one hand, a flood of ideas might spark creativity or new ways of approaching a project.

On the other hand, it can make it nearly impossible to focus on one task at a time, leading to disorganization and incomplete work.

Imagine your teen sitting down to do their homework, only to be bombarded by thoughts of everything else they need to do, the conversations they had that day, or even what they want to eat for dinner. It's easy for them to get lost in this mental chatter, pushing their homework to the back of their mind. They may convince themselves that they can handle it later. Still, as the thoughts keep racing, the task becomes more daunting and easier to ignore.

This struggle isn't just about being lazy or unwilling to work; it's a neurological challenge that makes it difficult for teens with ADHD to prioritize and manage their time effectively. The longer they delay, the more their anxiety builds, creating a cycle of avoidance and guilt . Parents may see this as defiance or lack of responsibility, but it's often a coping mechanism for dealing with the overwhelming nature of their thoughts.

The Promise of "Later" and the Reality of Procrastination

For many teens with ADHD, the word "later" is a frequent refrain. They promise to do their homework after dinner, before bed, or even first thing in the morning. However, "later" often never comes. This habit of putting things off can be particularly damaging when it comes to schoolwork, as deadlines pass, grades slip, and the pile of incomplete assignments grows.

Procrastination is a well-known companion of ADHD. It's not that these teens don't care about their work; they often care deeply, but feel paralyzed by the thought of starting. The task ahead seems so large and overwhelming that it's easier to push it off to some vague point in the future. Unfortunately, this approach only leads to more stress and fewer completed assignments.

Parents might find themselves in a constant battle to get their teen to start their homework, but addressing the underlying issues of procrastination and time management is necessary for these efforts to feel worthwhile. The cycle continues, with the teen promising to do better next time, but without concrete strategies in place, those promises often fall by the wayside.

The Necessity of Structured Intervention

Given these challenges, it's clear that teens with ADHD need more than just reminders or encouragement to complete their schoolwork. They need a structured intervention that forces them to set aside specific times to focus on their academic tasks. A rigid schedule can be a lifesaver in this case.

A rigid schedule may sound harsh, but for a teen with ADHD, it can provide the structure they need to succeed. By setting aside specific times each day for homework and study, your teen can build a routine that helps them manage their time more effectively. This doesn't mean every moment of their day needs to be planned out, but having designated periods for academic work can help them avoid the temptation to procrastinate.

It's important to work with your teen to create a realistic schedule that is tailored to their needs. This might involve breaking down larger tasks into smaller, more manageable steps and scheduling regular breaks to help them stay focused. The goal is to create a sense of predictability and routine, which can help reduce the anxiety and overwhelm that often accompany ADHD.

Parents play a crucial role in enforcing this schedule, but involving your teen in the process is also important. They need to feel a sense of ownership over their schedule, which can help them stay motivated and committed. Consistency is key, and while there will likely be bumps along the way, sticking to the schedule can help your teen develop better time management skills and a greater sense of control over their schoolwork.

The Role of an Executive Functioning Coach

One of the most effective interventions for teens with ADHD is working with an executive functioning coach. These professionals specialize in helping individuals develop the skills needed to manage time, stay organized, and follow through on tasks. An executive functioning coach can be a game-changer for a teen struggling with schoolwork.

An executive functioning coach works with your teen to develop personalized strategies for managing their schoolwork. This might include setting up a homework routine, using planners or digital tools to track assignments, and learning techniques for staying focused. The coach also helps your teen develop the self-discipline needed to stick to their schedule, which is often the most challenging part of the process.

Coaching is not just about teaching skills; it's about providing ongoing support and accountability. Many teens with ADHD benefit from having someone outside of their family who can help them stay on track and offer encouragement when they struggle.

By implementing a structured schedule and working with an executive functioning coach, you can help your teen develop the skills they need to stay organized, complete their homework on time, and achieve their academic goals .

Langberg, J. M., Epstein, J. N., Urbanowicz, C. M., Simon, J. O., & Graham, A. J. (2008). Efficacy of an Organization Skills Intervention to Improve the Academic Functioning of Students With Attention-Deficit/Hyperactivity Disorder. School Psychology Quarterly, 23 (3), 407-417.

Sibley MH, Graziano PA, Kuriyan AB, Coxe S, Pelham WE, Rodriguez L, Sanchez F, Derefinko K, Helseth S, Ward A. Parent-teen behavior therapy + motivational interviewing for adolescents with ADHD. J Consult Clin Psychol. 2016 Aug;84(8):699-712. doi: 10.1037/ccp0000106. Epub 2016 Apr 14. PMID: 27077693; PMCID: PMC4949080.

Evans SW, Langberg J, Raggi V, Allen J, Buvinger EC. Development of a school-based treatment program for middle school youth with ADHD. J Atten Disord. 2005 Aug;9(1):343-53. doi: 10.1177/1087054705279305. PMID: 16371680.

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Sticking up for yourself is no easy task. But there are concrete skills you can use to hone your assertiveness and advocate for yourself.

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Fbi is still mishandling child sex crimes even after nassar case, watchdog finds.

The Justice Department’s internal watchdog has found continued shortfalls in the FBI’s handling of tips about child sexual abuse despite a series of changes put in place following the bureau’s bungled handling of the Larry Nassar scandal .

Inspector General Michael Horowitz’s office examined 327 cases between October 2021 and late February 2023. It says it found no evidence that FBI employees complied with mandatory reporting requirements to local or state law enforcement in nearly half the cases.

“It’s critically important that the FBI appropriately handle all allegations of hands-on sex offenses against children,” Horowitz said. “Because failure to do so can result in children continuing to be abused and perpetrators abusing more children.”

In one of the cases examined in the audit, the inspector general’s office found that a registered sex offender allegedly victimized a minor for a 15-month period after the FBI initially became aware of the abuse allegations.

In its response to the audit, the FBI said in a letter to the IG that it takes seriously the “significant compliance issues” outlined in the report, and will “continue to work urgently to correct them.”

The latest inquiry follows the inspector general’s examination of how the FBI handled sexual abuse allegations against Larry Nassar, the longtime USA Gymnastics doctor who sexually abused gymnasts—including members of the U.S. women’s national team-—for years.

FBI had vowed to change

In that case, the FBI took few steps to act on tips that Nassar abused young gymnasts, and also failed to share information with other FBI offices or state and local authorities.

In the wake of the Nassar scandal, FBI Director Christopher Wray said the bureau's failed to protect the victims.

"It never should have happened, and we're doing everything in our power to make sure it never happens again," he told Congress at the time.

At the same time, the FBI began to make changes to how it documents and reviews cases of child sexual abuse, including steps to ensure that complaints are addressed quickly.

But the new report from the inspector general makes clear that the FBI is still falling short in several areas, including in reporting suspected child abuse to other law enforcement agencies, and in sharing of tips with other FBI field offices.

In a statement, the Democratic chairman of the Senate Judiciary Committee, Dick Durbin (Ill.), said “it’s shameful that the FBI is continuing to fail victims.”

“Today’s report shows that new policies implemented by the FBI to address these egregious failures are effectively being ignored, leading to similar abuses as seen in the Nassar investigation," he said.

Also flawed tip system

All FBI personnel are required to report suspected child abuse to state, local and tribal law enforcement and social services. But in 47% of the cases the inspector general reviewed, it found “no evidence” that FBI employees complied with mandatory reporting requirements.

Of the reports that were filed, it said, only 43% were made within 24 hours, as required by FBI policy.

The inspector general found similar shortcomings with the FBI’s compliance with its new tips management system, including a policy that requires verbal contact and a confirmed receipt when transferring abuse complaints or cases between FBI field offices.

The report found that the FBI did not document and process all allegations into its new system, and in 73% of cases or allegations transferred between field offices, there was no evidence of verbal contact or confirmed receipt as required by FBI policy.

Durbin, the Judiciary Committee head, said he would hold a hearing on the matter later this year.

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Religious Studies’ Brian Clites weighs in on unusual case of Catholic priests who filed for custody of a 2-year-old child in Steubenville, Ohio

Amid unusual and ongoing court battle, 2 priests in Steubenville, Ohio, seek custody of 2-year-old

Pittsburgh Post-Gazette :  Brian Clites , assistant professor of religious studies and the Archbishop Hallinan Professor of Catholic Studies II at the College of Arts and Sciences, weighed in on an unusual case of Catholic priests who filed for custody of a 2-year-old child in Steubenville, Ohio.