adhd child case study

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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.

Best, J. R., & Miller, P. H. (2010). A developmental perspective on executive function.  Child Development, 81 (6), 1641-1660.

Cremone-Caira, A., Root, H., Harvey, E. A., McDermott, J. M., & Spencer, R. M. (2019). Effects of sleep extension on inhibitory control in children with ADHD: A pilot study.  Journal of Attention Disorders , 1087054719851575.

Corkum, P., Tannock, R., & Moldofsky, H. (1998). Sleep disturbances in children with attention-deficit/hyperactivity disorder.  Journal of the American Academy of Child & Adolescent Psychiatry, 37 , 637-646.

Cordier, R., Bundy, A., Hocking, C., & Einfeld, S. (2010). Empathy in the play of children with attention deficit hyperactivity disorder.  OTJR: Occupation, Participation, and Health, 30 (3), 122-132.

Diamond, A. (2012). Activities and programs that improve children’s executive functions.  Current Directions in Psychological Science, 21 (5), 335-341.

Levanon-Erez, N., Cohen, M., Traub Bar-Ilan, R., & Maeir, A. (2017). Occupational identity of adolescents with ADHD: A mixed methods study.  Scandinavian journal of occupational therapy, 24 (1), 32-40.

Hahn-Markowitz, J., Berger, I., Manor, I., & Maeir, A. (2016). Efficacy of cognitive-functional (Cog-Fun) occupational therapy intervention among children with ADHD: An RCT.  Journal of Attention Disorders , 1087054716666955.

Faber Taylor, A., & Kuo, F. E. (2011). Could exposure to everyday green spaces help treat ADHD? Evidence from children's play settings.  Applied Psychology: Health and Well‐Being, 3 (3), 281-303.

Fricke L, Mitschke A, Wiater A, Lehmkuhl G. 2006. A new treatment program for children with sleep disorders – concept, practicability, and first empirical results.  Prax Kinderpsychol Kinderpsychiatr 55 :141–154. 

Keshavarzi, Z., Bajoghli, H., Mohamadi, M. R., Salmanian, M., Kirov, R., Gerber, M., ... & Brand, S. (2014). In a randomized case–control trial with 10-years olds suffering from attention deficit/hyperactivity disorder (ADHD) sleep and psychological functioning improved during a 12-week sleep-training program.  The World Journal of Biological Psychiatry, 15 (8), 609-619.

Kuhn BR, Floress MT. (2008).  Nonpharmacological interventions for sleep disorders in children. In Ivanenko A, ed.  Sleep and psychiatric disorders in children and adolescents . New York, NY: Informa Healthcare USA Inc. pp 261–278.

Majored, M., Tüchelmann, T., & Heusser, P. (2004). Therapeutic Eurythmy—movement therapy for children with attention deficit hyperactivity disorder (ADHD): a pilot study.  Complementary therapies in Nursing and Midwifery, 10 (1), 46-53.

Pan, C. Y., Tsai, C. L., Chu, C. H., Sung, M. C., Huang, C. Y., & Ma, W. Y. (2019). Effects of physical exercise intervention on motor skills and executive functions in children with ADHD: A pilot study.  Journal of Attention Disorders, 23 (4), 384-397.

Papadopoulos, N., Stavropoulos, V., McGinley, J., Bellgrove, M., Tonge, B., Murphy, A., ... & Rinehart, N. (2019). Moderating effect of motor proficiency on the relationship between ADHD symptoms and sleep problems in children with attention deficit hyperactivity disorder–combined type.  Behavioral Sleep Medicine, 17 (5), 646-656.

Tandon, P. S., Sasser, T., Gonzalez, E. S., Whitlock, K. B., Christakis, D. A., & Stein, M. A. (2019). Physical activity, screen time, and sleep in children with ADHD.  Journal of Physical Activity and Health, 16 (6), 416-422.

Toplak, M. E., West, R. F., & Stanovich, K. E. (2017). The assessment of executive functions in attention-deficit/hyperactivity disorder: Performance-based measures versus ratings of behavior.

Tseng, M. H., Henderson, A., Chow, S. M., & Yao, G. (2004). Relationship between motor proficiency, attention, impulse, and activity in children with ADHD.  Developmental Medicine and Child Neurology, 46 (6), 381-388.

Wilkes-Gillan, S., Bundy, A., Cordier, R., Lincoln, M., & Chen, Y. W. (2016). A randomised controlled trial of a play-based intervention to improve the social play skills of children with attention deficit hyperactivity disorder (ADHD).  PLOS one, 11 (8), e0160558

Yürümez, E., & Kılıç, B. G. (2016). Relationship between sleep problems and quality of life in children with ADHD.  Journal of Attention Disorders, 20 (1), 34-40.

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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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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About the author

Clinical partners, author's recent posts.

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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Article Contents

Conceptual framework, evolving definitions of adhd, what are the academic and educational characteristics of children with adhd, are academic and educational problems transient or persistent, what are the academic characteristics of children with symptoms of adhd but without formal diagnoses, how do treatments affect academic and educational outcomes, how should we design future research to determine which treatments improve academic and educational outcomes of children with adhd.

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Academic and Educational Outcomes of Children With ADHD

ADHD Special Issue, reprinted by permission from Ambulatory Pediatrics, Vol. 7, Number 2 (Supplement), Jan./Feb. 2007,

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Irene M. Loe, Heidi M. Feldman, Academic and Educational Outcomes of Children With ADHD, Journal of Pediatric Psychology , Volume 32, Issue 6, July 2007, Pages 643–654, https://doi.org/10.1093/jpepsy/jsl054

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Attention-deficit/hyperactivity disorder (ADHD) is associated with poor grades, poor reading and math standardized test scores, and increased grade retention. ADHD is also associated with increased use of school-based services, increased rates of detention and expulsion, and ultimately with relatively low rates of high school graduation and postsecondary education. Children in community samples who show symptoms of inattention, hyperactivity, and impulsivity with or without formal diagnoses of ADHD also show poor academic and educational outcomes. Pharmacologic treatment and behavior management are associated with reduction of the core symptoms of ADHD and increased academic productivity, but not with improved standardized test scores or ultimate educational attainment. Future research must use conceptually based outcome measures in prospective, longitudinal, and community-based studies to determine which pharmacologic, behavioral, and educational interventions can improve academic and educational outcomes of children with ADHD.

Problems in school are a key feature of attention-deficit/hyperactivity disorder (ADHD), often bringing the child with ADHD to clinical attention. It is important to establish the nature, severity, and persistence of these school difficulties in children with ADHD. It is also critical to learn how various treatments affect academic and educational outcomes. These findings inform clinical practice, public health, public education, and public policy. This review of academic and educational outcomes of ADHD is organized around 5 questions: (1) What are the academic and educational characteristics of children with ADHD? (2) Are academic and educational problems transient or persistent? (3) What are the academic characteristics of children with symptoms of ADHD but without formal diagnoses? (4) How do treatments affect academic and educational outcomes? (5) How should we design future research to determine which treatments improve academic and educational outcomes of children with ADHD?

We used the International Classification of Functioning, Disability, and Health (ICF) 1 as the conceptual framework for describing the functional problems associated with ADHD. The World Health Organization developed the ICF to provide a systematic and comprehensive framework and common language for describing and assessing functional implications of health conditions, regardless of the specific disease or disorder. Use of this model facilitates comparisons of health-related states across conditions, studies, interventions, populations, and countries.

In the underlying ICF conceptual framework, health conditions impact function at 3 mutually interacting levels of analysis ( Figure 1 ): body functions and structures, activities of daily living, and social participation. Problems of body functions and structures are called impairments , a more specific and narrow meaning for the term than that used in DSM-IV. 2 Problems of activities of daily living are called limitations . Problems of social participation are called restrictions. Environmental and personal factors can also affect functioning. Treatments may address the health condition directly, may be aimed at one or more domains within the levels of functioning, or may be designed to change the environment. Because of the bidirectional influences within and among these levels of analysis, treatments directed at one problem may indirectly improve problems at other levels.

Conceptual model of International Classification of Functioning, Disability, and Health.

Figure 2 applies the ICF model to school functioning in children with ADHD using the specific codes and terminology of the classification system. At the level of body functions, ADHD affects several global and specific mental functions: intellectual function; impulse control; sustaining and shifting attention; memory; control of psychomotor functions; emotion regulation; higher level cognition, including organization, time management, cognitive flexibility, insight, judgment, and problem solving; and sequencing complex movements. At the level of activities, ADHD may result in limitations in at least 2 domains relevant to this review (and other domains addressed by other chapters in this volume): (1) learning and applying knowledge, including reading, writing, and calculation; and (2) general tasks and demands, including completing single or multiple tasks, handling one's own behavior, and managing stress and frustration. Here, we will differentiate between academic underachievement , which will refer to problems in learning and applying knowledge, including earning poor grades and low standardized test scores, and academic performance , which includes completing classwork or homework. At the level of social participation, ADHD can compromise the major life area of education, including creating restrictions in moving in and across educational levels, succeeding in the educational program, and ultimately leaving school to work. Any one of these functional problems may have many contributors, including the health condition and functional problems at other levels of analysis. We will refer to the restrictions in participation as educational problems. Environmental factors relevant to outcomes in ADHD include general and special education services and policies.

Functional problems associated with attention-deficit/hyperactivity disorder using the International Classification of Functioning, Disability, and Health conceptual model.

The clinical criteria for ADHD have evolved over the last 25 years. Studies from the 1980s and 1990s often used different inclusion and exclusion criteria than were used in more recent studies. Some studies carefully differentiate between children with what we now label as ADHD-Combined subtype (ADHD-C) and attention deficit disorder or ADHD-predominantly Inattentive subtype (ADHD-I). We will address briefly the outcomes of the subtypes specifically. Many children with ADHD have comorbid conditions, including anxiety, depression, disruptive behavior disorders, tics, and learning problems. The contributions of these co-occurring problems to the functional outcomes of ADHD have not been well established. Therefore, in this review, we will consider the academic and educational outcomes of ADHD without subdividing the population on the basis of coexisting neurobehavioral problems in affected children.

Children with ADHD show significant academic underachievement, poor academic performance, and educational problems. 3–8 In terms of impairment of body functions, children with ADHD show significant decreases in estimated full-scale IQ compared with controls but score on average within the normal range. 9 In terms of activity limitations, children with ADHD score significantly lower on reading and arithmetic achievement tests than controls. 9 In terms of restrictions in social participation, children with ADHD show increases in repeated grades, use of remedial academic services, and placement in special education classes compared with controls. 9 Children with ADHD are more likely to be expelled, suspended, or repeat a grade compared with controls. 10

Children with ADHD are 4 to 5 times more likely to use special educational services than children without ADHD. 10, 11 Additionally, children with ADHD use more ancillary services, including tutoring, remedial pull-out classes, after-school programs, and special accommodations.

The literature reports conflicting data about whether the academic and educational characteristics of ADHD-I are substantially different from the characteristics of ADHD-C. 12, 13 Some studies have not found different outcomes in terms of academic attainment, use of special services, and rates of high school graduation. 14 However, a large survey of elementary school students found children with ADHD-I were more likely to be rated as below average or failing in school compared with the children with ADHD-C and ADHD–predominantly hyperactive-impulsive subtype. 15 A subset of children with ADHD-I are described as having a sluggish cognitive tempo, leading to the assumption that there is a higher prevalence of learning disorders in the ADHD-I than the ADHD-C populations. One study supporting this claim found more children with ADHD-I than children with ADHD-C in classrooms for children with learning disabilities. 16 Comparative long-term outcome studies of the subtypes in terms of academic and educational outcomes have not been conducted. 17

Longitudinal studies show that the academic underachievement and poor educational outcomes associated with ADHD are persistent. Academic difficulties for children with ADHD begin early in life. Symptoms are commonly reported in children aged 3 to 6 years, 18 and preschool children with ADHD or symptoms of ADHD are more likely to be behind in basic academic readiness skills. 19, 20

Several longitudinal studies follow school-age children with ADHD into adolescence and young adulthood. Initial symptoms of hyperactivity, distractibility, impulsivity, and aggression tend to decrease in severity over time but remain present and increased in comparison to controls. 21 In terms of activity limitations, subjects followed into adolescence fail more grades, achieve lower ratings on all school subjects on their report cards, have lower class rankings, and perform more poorly on standardized academic achievement tests than matched normal controls. 22–26 School histories indicate persistent problems in social participation, including more years to complete high school, lower rates of college attendance, and lower rates of college graduation for subjects than controls. 27–30

The subjects with ADHD in the longitudinal studies generally fall into 1 of 3 main groups as young adults: (1) approximately 25% eventually function comparably to matched normal controls; (2) the majority show continued functional impairment, limitations in learning and applying knowledge, and restricted social participation, particularly poor progress through school; and (3) less than 25% develop significant, severe problems, including psychiatric and/or antisocial disturbance. 31 It is unclear what factors determine the long-term outcomes. Persistent difficulties may be due to ADHD per se or may be due to a combination of ADHD and coexisting conditions, including learning, internalizing, and disruptive behavior disorders. The contribution of environmental factors to outcomes is also unclear.

Studies of outcome in children diagnosed with ADHD suffer from a potentially serious logical problem: circularity. 32 The clinical definition of ADHD in the DSM-IV requires the presence of functional impairment, typically defined in terms of behavior and performance at home and school. School problems are almost always present to make the diagnosis and therefore are more likely to be present at follow-up. Another problem in the use of clinic-referred samples is the selection bias in who gets referred to diagnostic clinics. One research strategy to complement the longitudinal studies of clinic-referred samples and avoid these problems is to evaluate children from community-based samples who demonstrate symptoms of ADHD but who have not necessarily been formally diagnosed with ADHD. In general, these studies find that children with symptoms of ADHD and without formal diagnoses also have adverse outcomes.

An early community-based study that charted the natural history of ADHD 33 followed subjects who were diagnosed and treated during childhood and children with symptoms and/or behavior indications who were never diagnosed or treated. Both groups were far more likely to attend special education schools and far less likely to graduate from high school or go to college than the asymptomatic controls. The magnitude of the difference was greater for the children with formal diagnosis than for those with pervasive symptoms.

Another community-based study on the relationship between symptoms of ADHD, scores on academic standardized tests, and grade retention found a linear relationship between the number of behavioral symptoms and academic achievement, even among children whose scores were generally below the clinical threshold for the diagnosis of ADHD. 34 Similar findings have been found in studies from Britain 35 and New Zealand. 36 Taken together, these findings suggest that the symptoms and associated features of ADHD are associated with adverse outcomes.

By using the ICF framework, treatments can be evaluated in terms of whether they improve body functions, including intelligence, sustained attention, memory, or executive functions; affect activities, including increasing learning and applying knowledge (such as raising standardized test scores or grades in reading, mathematics, or writing) and improving attending and completing tasks; or enhance participation, including moving across educational levels, succeeding in the educational program, and leaving school for work.

Medical Treatments

Psychopharmacological treatments, particularly with stimulant medications, reduce the core symptoms of ADHD 37 at the level of body functions. In addition, psychopharmacological treatments have been shown to improve children's abilities to handle general tasks and demands; for example, medication has been shown to improve academic productivity as indicated by improvements in the quality of note-taking, scores on quizzes and worksheets, the amount of written-language output, and homework completion. 38 However, stimulants are not associated with normalization of skills in the domain of learning and applying knowledge. 39 For example, stimulant medications have not generally been associated with improvements in reading abilities. 40, 41 In longitudinal studies, subjects demonstrated poor outcomes compared with controls whether or not they received medication. 24 , ,25 ,27 ,42–44 One caution in interpreting these findings is that it cannot be determined if outcomes would have been even worse without treatment because studies often lacked a true nontreatment group with ADHD. Another problem was attrition; subjects lost to follow-up may include those with worse outcomes. A third caution is that most children receive medication for only 2 to 3 years, 45 and it remains unclear whether steady treatment over many years would be associated with improved outcomes.

Behavior Management of ADHD

Behavioral interventions for ADHD, including behavioral parent training, behavioral classroom interventions, positive reinforcement and response cost contingencies, are effective in reducing core ADHD symptoms. 17 , ,30 ,46 However, in head-to-head comparisons behavior management techniques are less effective than psychostimulant medications 37 in reducing core symptoms. It has been shown that behavior management is equivalent or better than medication in improving aspects of functioning, such as parent-child interactions and reduction in oppositional-defiant behavior. However, the problem with this literature is that most behavior management intervention studies evaluate the impact on short-term behavior outcomes, not academic and educational outcomes. The impact of behavioral treatments on long-term academic and educational outcomes must be carefully studied.

Combined Management of ADHD

Given the chronic nature of ADHD and its impact on multiple domains of function, it is likely that multiple treatment approaches are needed. However, the impact of such combined treatments on long-term academic and educational outcomes has not been well studied. Combined treatment (medication and behavioral treatment) in the Multimodal Treatment Study of Children With ADHD was better than behavioral treatment and community care for reading achievement; however, the differences were small and of questionable clinical significance. 37 In addition, children with ADHD and co-occurring anxiety or environmental adversity derived benefit from the combination of medication and behavior management. 47, 48 We need studies to determine whether combined treatment has a larger impact on academic and educational outcomes in some subpopulations than others.

In terms of academic achievement and performance, a 2-year study comparing therapy with methylphenidate to therapy with methylphenidate plus multimodal psychosocial treatments found no advantage of combined treatment over medication alone on any academic measures. 49 The multimodal treatment included academic assistance, organizational skills training, individual psychotherapy, social skills training, and, if needed, reading remediation using phonics. In these studies, medication and/or behavior management, whether used alone or in combination, did not improve academic and educational outcomes of ADHD.

Educational Interventions and Services

The impact of remedial educational services on academic and educational outcomes is not known. Most available treatment outcome studies have not been conducted in general education classroom settings 50 and have focused on reducing problematic behavior rather than on improving scholastic status. 51 Even current rates of utilization are difficult to determine because ADHD itself is not an eligibility criterion for special education. 52 Although advocates pursued making ADHD a category of disability under the Individuals with Disabilities Education Act of 1990 (IDEA), this attempt was not successful. 53 Instead, the US Department of Education issued a policy memorandum 54 stating that students with ADHD were eligible for special education services under the Other Health Impairment category if problems of limited alertness negatively affected academic performance. Children with ADHD may qualify for special education services if they are eligible for another IDEA category, such as emotional disturbance or specific learning disability, but the children with ADHD are not disaggregated from students without ADHD in these categories. 55

Educational services are also provided to students with ADHD who do not meet IDEA eligibility requirements under Section 504 of the Vocational Rehabilitation Act of 1973 if the condition substantially limits a major life activity, such as learning. 53 Services include accommodations and related services in the general education setting, such as preferential seating, modified instructions, reduced classroom and homework assignments, and increased time or environmental modification for test taking. There is wide variability in the knowledge and application of Section 504 services among parents and educators. 53

For both special education and Section 504 services, the children most likely to obtain services are those with the most severe functional limitations. Therefore, it would be difficult to interpret associations among use of services and outcomes. There are no data regarding effectiveness of many commonly recommended accommodations, such as preferential seating, on outcomes.

The evidence that ADHD is associated with poor academic and education outcomes is overwhelming. However, studies thus far find that treatments are associated with relatively narrow improvements in core symptoms of inattention, hyperactivity, and impulsivity at the level of body functions and attending and completing tasks at the level of activities. We need prospective, controlled, and large-scale studies to investigate whether existing or new treatments will improve reading, writing, and mathematics skills; reduce grade retention; reduce expulsions and detentions; improve graduation rates; and increase completion of postsecondary education. In a literate, information-age society, these improved outcomes are vital to the economic and personal well-being of individuals with ADHD.

Because of the limitations of previous research, we recommend that future research incorporate several features. In terms of the subjects, the study must specify clear inclusion criteria, including diagnostic criteria for ADHD, subtypes, and coexisting conditions. Given the research history to date, we favor community- or school-based samples as opposed to clinic-referred samples to avoid selection bias. Studies should be conducted in general education as well as secondary school settings, given the lack of data from these settings. In terms of the outcome variables, we support use of standardized definitions of functional outcomes following the conceptualization of function provided by the ICF framework. We specifically favor repeated measures of academic achievement. Unfortunately, measures such as grades may vary across school systems. For this reason, the use of achievement tests may be preferable in large-scale studies. In addition, measures relevant to educational promotion, such as college entrance examinations, may provide more standardized information than graduation rates. In local or regional studies, other repeated measures may be possible, including analysis of portfolios. Another sensitive measure that could be collected on a continuous basis is curriculum-based measurement, 56 which involves probes of reading and math performance relative to the instructed curriculum and permits examination of relative trajectories over time as a measure of treatment outcome.

Designing convincing studies on the long-term impact of medication or behavior management on academic and educational outcomes is challenging because it is unethical to withhold standard treatments for long periods of time from an affected sample to create a control group. To circumvent this problem, we suggest large-scale studies that evaluate rates of change in the outcomes as a function of treatment strategy (or intensity) and that use statistical methods such as hierarchical linear modeling. 57 In this approach, individual students are nested in hierarchies that are defined by grade and diagnosis and also by treatment type and intensity. Repeated measures for outcomes, such as reading or math standard scores, are collected over time. The statistical methods estimate the effects of each factor—age and treatment intensity—on the rate of change. This method can demonstrate if the rate of change increases more rapidly in some groups than other groups and more rapidly than would have been predicted on the basis of status at study entry. The hierarchical linear modeling method is also helpful with differentiating rates of progress among children who adhere to treatment recommendations over long periods of time versus those who discontinue treatment after a few months or years.

We also recommend that the research strategy incorporate a 2-tiered approach. First, improvements in instruction/teaching methods, curriculum design, school physical designs, and environmental modifications should be offered to all students. We can call this phase improved universal design. Schools often try to change the child with ADHD to fit the school environment. Attempts to “normalize” behavior include pulling a child out of the classroom, perhaps applying a remedial strategy, and then putting the child back into the original setting, with the hope that the child will now be successful. 58 This strategy identifies the child as the problem, serves to isolate and potentially stigmatize the child, and precludes the exploration of environment-based solutions. 59 The advantage of universal design is that most children with ADHD are educated in general education settings. Improved universal design in the classroom could potentially benefit all children in the classroom, particularly those with ADHD. Such interventions may not decrease the differences between children with ADHD and their peers without ADHD on some measures, such as standardized test scores. However, more important is whether the children with ADHD reach a higher threshold of achievement, such as improved reading scores or higher rates of high school graduation.

The second tier for research is specific interventions for children with ADHD, layered on top of the basic reforms. These interventions can include teaching methods, new curricula, specific behavior management, and school-based intervention approaches. 60

We will focus on 6 different options that warrant further investigation in this 2-tiered research design: (1) small class size; (2) reducing distractions; (3) specific academic intervention strategies; (4) increased physical activity; (5) alternative methods of discipline; and (6) systems change.

Small Class Size

A study based in London schools of regular education students found that variations in average class size in the 25- to 35-student range are of little consequence in affecting student progress, probably because of a lack of opportunity for differences in classroom management techniques. 61 However, small classes of approximately 8 to 15 students have been beneficial for younger children and children with special needs. 62 Because children with ADHD are reported to do better with one-on-one instruction, smaller class size makes intuitive sense. Teachers perceive class size to be one of the major barriers to inclusion of ADHD students in regular education. 63 Empiric investigation on reduced class size is therefore warranted for all children, and also for children with ADHD. Small class sizes will probably result in use of innovative educational approaches that are precluded in the current system.

Reducing Distractions

Classrooms are often noisy and distracting environments. Children perform more poorly in noisy situations than do adults, and researchers have reported that the ability to listen in noise is not completely developed until adolescence or adulthood. 64–66 If an acoustic environment can be provided that allows +15 dB signal-to-noise ratio throughout the entire classroom, then all participants can hear well enough to receive the spoken message fully. 64 Accommodations in Section 504 plans often include repeating instructions and providing quiet test-taking areas that are free of distractions. Repetition of instructions alone is not likely to increase the attention of children with ADHD. Thus, methods for reducing noise and other distractions should be studied.

Specific Academic Intervention Strategies

As reviewed by Hoffman and DuPaul, 51 the so-called antecedent-oriented management strategies are good universal design features that hold promise for improving outcomes for children with ADHD. Antecedent interventions include choice making, peer tutoring, and computer-aided instruction, all reviewed below. Such strategies are proactive, support appropriate adaptive behavior, and prevent unwanted, challenging behaviors. These strategies make tasks more stimulating and provide students with opportunities to make choices related to academic work. 67 They may be particularly helpful for children with ADHD who demonstrate avoidance and escape behaviors.

Choice-making strategies allow students to select work from a teacher-developed menu. In a study of choice making with children with emotional and behavioral difficulties in a special education classroom, students demonstrated increased academic engagement and decreased behavior problems. 68 Another study demonstrated decreased disruptive behavior in a general education setting, 69 although more variable academic and behavioral performance occurred in a study of 4 students with ADHD in a general education setting. 51 A related concept is project-based learning, which capitalizes on student interests and provides a dynamic, interactive way to learn.

Studies of Class Wide Peer Tutoring, a widely used form of peer tutoring, have demonstrated enhanced task-related attention and academic accuracy in elementary school students with ADHD, 70, 71 as well as positive changes in behavior and academic performance in students without ADHD. 72 Teachers perceive time requirements of specialized interventions as a significant barrier to the inclusion of ADHD students. 63 Peer tutoring reduces the demands on teachers to provide one-on-one instruction. At the same time, it gives students with ADHD the opportunity to practice and refine academic skills, as well as to enhance peer social interactions, promoting self-esteem. Peer tutoring may be particularly effective when students are using disruptive behavior to gain peer attention. 51

Computer-aided instruction has intuitive appeal as a universal design feature and for children with ADHD because of its interactive format, use of multiple sensory modalities, and ability to provide specific instructional objectives and immediate feedback. Computer-aided instruction has not been well studied in children with ADHD. 51, 73 Studies with small numbers of subjects showed promising initial results 74, 75 but did not examine the effects on academic achievement. A small study of 3 children with ADHD that used a game-format math program found increases in academic achievement and increased task engagement. 76

Increased Physical Activity

Given that fidgeting and out-of-seat behavior are common in children with ADHD, increased use of recess and physical exercise might reduce overactivity. A study on the effects of a traditional recess on the subsequent classroom behavior of children with ADHD showed that levels of inappropriate behavior were consistently higher on days when participants did not have recess, compared with days when they did have recess. 77 A meta-analysis of studies on the effects of regular, noncontingent exercise showed reductions in disruptive behavior with greater effects in participants with hyperactivity. 78 Increased physical exercise would be beneficial for long-term health and for behavioral regulation in both children developing typically and children with ADHD.

Alternative Methods of Discipline

Many students receive suspensions or are sent to the principal's office for disruptive behavior. For those children who are avoiding work, these approaches are equivalent to positive reinforcement. Such avoidant or escape behavior could be countered with in-school as opposed to out-of-school suspensions. The use of interventions that teach children how to replace disruptive behaviors with appropriate behaviors is less punitive than suspensions and more effective in promoting academic productivity and success. 17

Systems Change

Classroom changes are unlikely to create adequate improvements without concomitant changes in the educational system. Three potential areas under the category of systems change are improved education of teachers and educational administrators; enhanced collaborations among family members, school professionals, and health care professionals; and improved tracking of child outcomes. Teacher surveys demonstrate that teachers perceive the need for more training about ADHD. 63 The optimal management of children with ADHD requires close collaboration of their parents, teachers, and health care providers. Currently there is no organized system to support this collaboration.

At the policy level, we need mechanisms to track the outcome of children with ADHD in relation to educational reform and utilization of special services. Federally supported surveys could focus on services and treatments for mental health conditions, including ADHD, and their impact on outcomes. Relevant data for the relationship of interventions and outcomes may also exist at the local and state level. Building on existing local and state databases to include health and mental health statistics could provide valuable information on this issue.

We remain ill informed about how to improve academic and educational outcomes of children with ADHD, despite decades of research on diagnosis, prevalence, and short-term treatment effects. We urge research on this important topic. It may be impossible to conduct long-term randomized, controlled trials with medication or behavior management used as treatment modalities for practical and ethical reasons. However, large-scale studies that use modern statistical methods, such as hierarchical linear modeling, hold promise for teasing apart the impact of various treatments on outcomes. Such methods can take into account the number and types of interventions, duration of treatment, intensity of treatment, and adherence to protocols. Educational interventions for children with ADHD must be studied. We recommend large-scale, prospective studies to evaluate the impact of educational interventions. These studies should be tiered, introducing universal design improvements and specific interventions for ADHD. They must include multiple outcomes, with emphasis on academic skills, high school graduation, and successful completion of postsecondary education. Such studies will be neither cheap nor easy. A broad-based coalition of parents, educators, and health care providers must work together to advocate for an ambitious research agenda and then design, implement, and interpret the resulting research. Changes in local, state, and federal policies might facilitate these efforts by creating meaningful databases and collaborations.

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Attention Deficit Hyperactivity Disorder (ADHD): A Case Study and Exploration of Causes and Interventions

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• Bijal Chheda-Varma 5  

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The male to female ratio of ADHD is 4:1. This chapter on ADHD provides a wide perspective on understanding, diagnosis and treatment for ADHD. It relies on a neurodevelopmental perspective of ADHD. Signs and symptoms of ADHD are described through the DSM-V criteria. A case example (K, a patient of mine) is illustrated throughout the chapter to provide context and illustrations, and demonstrates the relative merits of “doing” (i.e. behavioural interventions) compared to cognitive insight, or medication alone. Finally, a discussion of the Cognitive Behavioral Modification Model (CBM) for the treatment of ADHD provides a snapshot of interventions used by clinicians providing psychological help.

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Alderson, R. M., Hudec, K. L., Patros, C. H. G., & Kasper, L. J. (2013). Working memory deficits in adults with attention-deficit/hyperactivity disorder (ADHD): An examination of central executive and storage/rehearsal processes. Journal of Abnormal Psychology, 122 (2), 532–541. http://dx.doi.org/10.1037/a0031742 .

Arcia, E., & Conners, C. K. (1998). Gender differences in ADHD? Journal of Developmental and Behavioral Pediatrics, 19 (2), 77–83. http://dx.doi.org/10.1097/00004703-199804000-00002 .

Barkley, R. A. (1990). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment . New York: Guildford.

Google Scholar  

Barkley, R. A. (1997). ADHD and the nature of self-control . New York: Guilford Press.

Barkley, R. A. (2000). Commentary on the multimodal treatment study of children with ADHD. Journal of Abnormal Child Psychology, 28 (6), 595–599. https://doi.org/10.1023/A:1005139300209 .

Article   Google Scholar  

Barkley, R., Knouse, L., & Murphy, K. Correction to Barkley et al. (2011). Psychological Assessment [serial online]. June 2011; 23 (2), 446. Available from: PsycINFO, Ipswich, MA. Accessed December 11, 2014.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders . New York, NY: International Universities Press.

Brown, T. E. (2005). Attention deficit disorder: The unfocused mind in children and adults . New Haven, CT: Yale University Press.

Brown, T. (2013). A new understanding of ADHD in children and adults . New York: Routledge.

Chacko, A., Kofler, M., & Jarrett, M. (2014). Improving outcomes for youth with ADHD: A conceptual framework for combined neurocognitive and skill-based treatment approaches. Clinical Child and Family Psychology Review . https://doi.org/10.1007/s10567-014-0171-5 .

Chronis, A., Jones, H. A., Raggi, V. L. (2006, August). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Clinical Psychology Review, 26 (4), 486–502. ISSN 0272-7358. http://dx.doi.org/10.1016/j.cpr.2006.01.002 .

Curatolo, P., D’Agati, E., & Moavero, R. (2010). The neurobiological basis of ADHD. Italian Journal of Pediatrics, 36 , 79. http://doi.org/10.1186/1824-7288-36-79 . http://www.sciencedirect.com/science/article/pii/S0272735806000031 .

Curtis, D. (2010). ADHD symptom severity following participation in a pilot, 10-week, manualized, family-based behavioral intervention. Child & Family Behavior Therapy, 32 , 231–241. https://doi.org/10.1080/07317107.2010.500526 .

De Young, R. (2014). Using the Stroop effect to test our capacity to direct attention: A tool for navigating urgent transitions. http://www.snre.umich.edu/eplab/demos/st0/stroopdesc.html .

Depue, B. E., Orr, J. M., Smolker, H. R., Naaz, F., & Banich, M. T. (2015). The organization of right prefrontal networks reveals common mechanisms of inhibitory regulation across cognitive, emotional, and motor processes. Cerebral Cortex (New York, NY: 1991), 26 (4), 1634–1646.

D’Onofrio, B. M., Van Hulle, C. A., Waldman, I. D., Rodgers, J. L., Rathouz, P. J., & Lahey, B. B. (2007). Causal inferences regarding prenatal alcohol exposure and childhood externalizing problems. Archives of General Psychiatry, 64, 1296–1304 [PubMed].

DSM-V. (2013). Diagnostic and statistical manual of mental disorders . American Psychological Association.

Eisenberg, D., & Campbell, B. (2009). Social context matters. The evolution of ADHD . http://evolution.binghamton.edu/evos/wp-content/uploads/2012/02/eisenberg-and-campbell-2011-the-evolution-of-ADHD-artice-in-SF-Medicine.pdf .

Gizer, I. R., Ficks, C., & Waldman, I. D. (2009). Hum Genet, 126 , 51. https://doi.org/10.1007/s00439-009-0694-x .

Hinshaw, S. P., & Scheffler, R. M. (2014). The ADHD explosion: Myths, medication, money, and today’s push for performance . New York: Oxford University Press.

Kapalka, G. M. (2008). Efficacy of behavioral contracting with students with ADHD . Boston: American Psychological Association.

Kapalka, G. (2010). Counselling boys and men with ADHD . New York: Routledge, Taylor & Francis Group.

Book   Google Scholar  

Knouse, L. E., et al. (2008, October). Recent developments in psychosocial treatments for adult ADHD. National Institute of Health, 8 (10), 1537–1548. https://doi.org/10.1586/14737175.8.10.1537 .

Laufer, M., Denhoff, E., & Solomons, G. (1957). Hyperkinetic impulse disorder in children’s behaviour problem. Psychosomatic Medicine, 19, 38–49.

Raggi, V. L., & Chronis, A. M. (2006). Interventions to address the academic impairment of children and adolescents with ADHD. Clinical Child and Family Psychology Review, 9 (2), 85–111. https://doi.org/10.1007/s10567-006-0006-0 .

Ramsay, J. R. (2011). Cognitive behavioural therapy for adult ADHD. Journal of Clinical Outcomes Management, 18 (11), 526–536.

Retz, W., & Retz-Junginger, P. (2014). Prediction of methylphenidate treatment outcome in adults with attention deficit/hyperactivity disorder (ADHD). European Archives of Psychiatry and Clinical Neuroscience . https://doi.org/10.1007/s00406-014-0542-4 .

Safren, S. A., Otto, M. W., Sprich, S., Winett, C. L., Wilens, T. E., & Biederman, J. (2005, July). Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behaviour Research and Therapy, 43 (7), 831–842. ISSN 0005-7967. http://dx.doi.org/10.1016/j.brat.2004.07.001 . http://www.sciencedirect.com/science/article/pii/S0005796704001366 .

Sibley, M. H., Kuriyan, A. B., Evans, S. W., Waxmonsky, J. G., & Smith, B. H. (2014). Pharmacological and psychosocial treatments for adolescents with ADHD: An updated systematic review of the literature. Clinical Psychology Review, 34 (3), 218–232. https://doi.org/10.1016/j.cpr.2014.02.001 .

Simchon, Y., Weizman, A., & Rehavi, M. (2010). The effect of chronic methylphenidate administration on presynaptic dopaminergic parameters in a rat model for ADHD. European Neuropsychopharmacology, 20 (10), 714–720. ISSN 0924-977X. https://doi.org/10.1016/j.euroneuro.2010.04.007 . http://www.sciencedirect.com/science/article/pii/S0924977X10000891 .

Swanson, J. M., & Castellanos, F. X. (2002). Biological bases of ADHD: Neuroanatomy, genetics, and pathophysiology. In P. S. Jensen & J. R. Cooper (Eds.), Attention deficit hyperactivity disorder: State if the science, best practices (pp. 7-1–7-20). Kingston, NJ: Civic Research Institute.

Toplak, M. E., Connors, L., Shuster, J., Knezevic, B., & Parks, S. (2008, June). Review of cognitive, cognitive-behavioral, and neural-based interventions for attention-deficit/hyperactivity disorder (ADHD). Clinical Psychology Review, 28 (5), 801–823. ISSN 0272-7358. http://dx.doi.org/10.1016/j.cpr.2007.10.008 . http://www.sciencedirect.com/science/article/pii/S0272735807001870 .

Wu, J., Xiao, H., Sun, H., Zou, L., & Zhu, L.-Q. (2012). Role of dopamine receptors in ADHD: A systematic meta-analysis. Molecular Neurobiology, 45 , 605–620. https://doi.org/10.1007/s12035-012-8278-5 .

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Chheda-Varma, B. (2019). Attention Deficit Hyperactivity Disorder (ADHD): A Case Study and Exploration of Causes and Interventions. In: Barry, J.A., Kingerlee, R., Seager, M., Sullivan, L. (eds) The Palgrave Handbook of Male Psychology and Mental Health. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-030-04384-1_15

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Childhood Trauma and ADHD: A Complete Overview & Clinical Guidance

Childhood trauma is linked to adhd, and vice versa. they share similar symptoms that are often confused and misdiagnosed. each also amplifies symptom severity in the other. these are just a few reasons why clinicians must increase their understanding of trauma and adopt an informed approach when assessing and treating children for adhd..

Trauma and traumatic stress, according to a growing body of research, are closely associated with attention deficit hyperactivity disorder (ADHD or ADD). Trauma and adversity can alter the brain’s architecture, especially in children, which may partly explain their link to the development of ADHD. ADHD and trauma can also present similar symptoms, which may complicate assessment. Trauma, if present with ADHD, can exacerbate ADHD symptoms. At the same time, ADHD may also increase the risk of exposure to trauma.

Our increasing knowledge of trauma’s impact necessitates trauma-informed approaches to ADHD assessment and treatment. For clinicians, especially, it’s critical to understand the relationship between ADHD and PTSD , what traumatic stress does to the brain, what may constitute trauma (including who is more at risk for experiencing unique traumatic stressors), and how to protect young patients against it.

Traumatic Stress as a Risk Factor for ADHD

Traumatic stress, apart from other factors like premature birth, environmental toxins, and genetics, is associated with risk for ADHD . The connection is likely rooted in toxic stress – the result of prolonged activation of the body’s stress management system.

Adversity and the Stress Response

When confronted with an acute adverse stressor, the body releases adrenaline, triggering the fight or flight response. Cortisol, a stress hormone, is also released, helping to mobilize the body’s energy stores, activate the immune system, and even briefly enhance memory.

When this stress response is activated in children in the context of supportive adult relationships, these physiological effects are buffered. However, when these buffering relationships are unavailable, and when the stress response is long lasting, toxic stress may be the outcome.

[ More Than Just Genes: How Environment, Lifestyle, and Stress Impact ADHD ]

Toxic Stress and the Brain

Studies indicate that toxic stress can have an adverse impact on brain development in children. Regions of the brain involved in fear, anxiety, and impulsivity may overproduce neural connections, while areas dedicated to reasoning, planning, and behavioral control may actually produce fewer neural connections. This may lead to what we term maladaptive behavioral responses – they include ADHD and other conditions like anxiety and mood disorders.

Toxic levels of stress hormones can even cause neuronal cell death, especially in the prefrontal cortex (a region associated with executive function, self-regulation, and attention) and the limbic systems (associated with learning, memory, emotional regulation, and reactivity).

Trauma and Adverse Childhood Experiences

Another way to understand how traumatic stress impacts ADHD and overall well-being is to look at the science behind adverse childhood experiences (ACEs). ACEs are stressful or traumatic events occurring before the age of 18 that have negative effects on physical, social, and emotional well-being. They include but are not limited to:

• Psychological
• Substance abuse
• Mental illness
• Domestic violence
• Incarceration

[ Read: The Neuroscience of the ADHD Brain ]

As ACEs accumulate, they also increase the odds of high-risk health behaviors and can eventually lead to the most severe outcome associated with ACEs: early death.

One study of more than 17,000 adults found that, as participants reported more adverse experiences in childhood, the chances of participating in risk behaviors and of developing a chronic disease also increased. 1 According to the study, adults with four or more ACEs are:

• More than twice as likely to have heart disease and experience stroke
• At about four times greater risk for chronic bronchitis or emphysema

The same study found that more than half of adults reported at least one adverse childhood experience, and more than a quarter reported two or more. Another national survey on children found similar results. 2

ACEs, Trauma, and ADHD

How do adverse experiences impact children with ADHD? Our research shows that children with ADHD across the board have higher rates of each ACE type compared to children without ADHD. 3 Our research also found the following:

• Socioeconomic hardship
• Familial mental illness
• Neighborhood violence
• As ACE scores increase, the risk of having also ADHD increases.
• Socioeconomic hardship and having a caregiver with a mental illness significantly increase the odds of a child having moderate to severe ADHD.

Our study, as is the case with many studies on ACEs and health, has some limitations:

• These studies do not measure when trauma occurred, its duration, or its severity.
• ACEs in these studies are also weighted equally, when in reality, some traumas are much more impactful than others.
• ACEs are past traumatic events, meaning there may not be a current experience of trauma.
• A history of adverse experiences in childhood alone isn’t diagnostic of having trauma.

Comparing ADHD and Trauma

Traumatic stress and ADHD affect the same areas of the brain, which can complicate ADHD symptoms assessments in children. Areas of overlap include:

• Difficulty concentrating and learning in school
• Distractibility
• Disorganization
• Often doesn’t seem to listen
• Difficulty sleeping
• Restlessness
• Hyperactivity

Trauma can make children feel agitated, troubled, nervous, and on high alert — symptoms that can be mistaken for ADHD. Inattention in children with trauma may also make them disassociate, which can look like a lack of focus — another hallmark symptom of ADHD. The fact that ADHD and child traumatic stress frequently co-occur with other conditions like mood disorders, anxiety, and learning disabilities make it all much harder to tease apart.

Trauma’s Impact on ADHD Symptoms

Traumatic stress can worsen ADHD symptoms. Up to 17% of trauma-exposed children meet ADHD criteria, and the co-occurrence of each worsens the effects of the other. Trauma also impacts specific brain regions that may also increase:

• Inattention, impulsivity, and hyperactivity
• Social difficulties
• Learning difficulties
• Symptoms of common co-occurring disorders (mood disorders, anxiety, conduct disorder)

Typical ACEs questionnaires, however, tend to exclude some traumatic experiences that often go unrecognized in children with ADHD but can impact symptoms, including death of a caregiver, community violence, and bullying.

ADHD vs PTSD

Despite symptom overlap, there are real differences between ADHD and post-traumatic stress disorder ( PTSD ), the result of a traumatic event that causes brain changes (note: the majority of children exposed to trauma do not meet criteria for PTSD).

• ADHD is widely considered a heritable condition, while PTSD occurs after experiencing trauma
• ADHD is characterized by deficits in attention, behavioral inhibition, and regulation. PTSD is characterized by avoidant and hypervigilant behavior, and re-experiencing of the trauma.
• ADHD’s symptoms are pervasive and cause significant functional limitations. PTSD causes physiologic, cognitive, and emotional changes in how a person processes stressors.

ADHD as a Risk Factor for Trauma

An ADHD diagnosis increases the risk of trauma exposure for several key reasons. Children with ADHD alone are at a heightened risk for factors that are strongly linked to trauma, including:

• Interpersonal and self-regulatory problems
• Co-occurring mental health disorders

Children with ADHD also have higher rates of child maltreatment and accidental traumas (i.e. injury).

Trauma and Children of Color

Clinicians must be aware of the traumatic stressors that children of color uniquely experience – namely, systemic and structural racism and concentrated poverty – that may worsen ADHD symptoms.

Studies show that individuals who experience microaggressions and persistent racism also demonstrate sustained toxic stress responses. Children of color are also at increased risk of living in concentrated poverty, which is tied to moderate and severe ADHD as well as having an ADHD diagnosis.

ADHD and Trauma: Assessment & Treatment Implications

Psychosocial history.

The standard screening tools for ADHD symptoms don’t systematically identify family environment factors, high-risk behaviors, and other adversities. Many clinicians neglect to ask about adverse childhood experiences – a recent study found that approximately one-third of pediatricians do not usually ask about any ACEs, while 4% reported usually asking about all ACEs types. 4 To forgo assessing psychosocial history means missing out on factors that play a role and potentially worsen ADHD symptoms, or inadvertently confusing traumatic stress for ADHD.

Clinicians should assess for traumatic events and the time they occurred while assessing for ADHD. A range of trauma screening tools are available (for a list of trauma screens, visit The National Child Traumatic Stress Network ).

It’s also important to assess the child’s strengths and sources of support, as they can build their capacity for resilience and can be leveraged when managing ADHD, traumatic stress, or both. Clinicians should gather information from a variety of perspectives, including parents, the school, other people in the child’s life, and even the child, if appropriate.

Minimize the Effects of Trauma & Toxic Stress

Several factors are known to buffer the effects of trauma and toxic stress in children, like:

• A supportive family environment and social networks
• Concrete support for basic needs
• Nurturing parenting skills
• Parent employment and education
• Adequate housing
• Access to health care and social services

An integrated healthcare model that includes wrap-around care coordination and partnerships with schools and community-based organizations is the best way to optimize these powerful, protective factors.

Trauma-Informed Care

Clinicians should remember these four “Rs” associated with trauma-informed care:

• Realize the widespread impact of trauma and understand potential paths for recovery
• Recognize the signs and symptoms of trauma in patients, families, staff, and others involved
• Respond by fully integrating knowledge about trauma into policies, procedures, and practices
• Resist re-traumatization of children and the adults who care for them

For children with co-occurring ADHD and traumatic stress , treatment includes but is not limited to the following:

• Clinical judgement on medication. Some studies suggest that those with PTSD symptoms may not react well to stimulant medications, which are first-line treatments for ADHD.
• Psychotherapy , including trauma-focused cognitive behavioral therapy (CBT).
• Relaxation and stress-management skills. Emerging science shows the benefits of mindfulness strategies as adjunctive treatment for children with ADHD, which has shown positive impacts on children who experience trauma.

ADHD and Trauma: Next Steps

• Read: ADHD, Trauma, and How Somatic Therapy Can Help
• Q&A: Did Childhood Trauma Cause My Son’s ADHD Behavior Problems?
• Learn: ADHD Neuroscience 101

The content for this article was derived from the ADDitude Expert Webinar “How Stress and Trauma Affect ADHD in Children of All Colors — and How to Heal the Wounds” by Nicole Brown, M.D., MPH, MHS, which was broadcast live on October 15, 2020.

SUPPORT ADDITUDE Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing . Your readership and support help make our content and outreach possible. Thank you.

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1 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245–258. https://doi.org/10.1016/s0749-3797(98)00017-8

2 Bethell, C. et. al. (2014). Adverse Childhood Experiences: Assessing The Impact On Health And School Engagement And The Mitigating Role Of Resilience. Health Affairs, 33(12). https://doi.org/10.1377/hlthaff.2014.0914

3 Brown, N. M., Brown, S. N., Briggs, R. D., Germán, M., Belamarich, P. F., & Oyeku, S. O. (2017). Associations Between Adverse Childhood Experiences and ADHD Diagnosis and Severity. Academic pediatrics, 17(4), 349–355. https://doi.org/10.1016/j.acap.2016.08.013

4 Kerker, B. D., Storfer-Isser, A., Szilagyi, M., Stein, R. E., Garner, A. S., O’Connor, K. G., Hoagwood, K. E., & Horwitz, S. M. (2016). Do Pediatricians Ask About Adverse Childhood Experiences in Pediatric Primary Care?. Academic pediatrics, 16(2), 154–160. https://doi.org/10.1016/j.acap.2015.08.002

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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.

Article visualizations:

Aiken, L.R. (1972). Research on attitudes toward mathematics. Arithmetic Teacher, 19, 229-234.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). Washington, DC: American Psychiatric Association.

Anastopulos, A.D., Spisto, M.A., & Maher, M.C. (1994). The WISC-III freedom from distractibility factor: Its utility in identifying children with attention deficit/hyperactivity disorder. Psychological Assessment, 6(4), 368-371.

Brown, V.L., Cronin, M.E., & McEntire, E. (1994). Test of Mathematical Abilities (2nd ed.): Examiner’s manual. Austin, TX: Pro-Ed.

Brown, V.L., & McEntire, E. (1984). Test of Mathematical Abilities (TOMA): A method for assessing mathematical aptitudes and attitudes. Austin, TX: Pro-Ed.

Brummitt-Yale, J. (2017). What is diagnostic assessment? - Definition & examples. Retrieved on 15 February, 2020, from: https://study.com/academy/lesson/what-is-diagnostic-assessment-definition-examples.html.

Chia, K.H. (2008). Educating the whole child in a child with special needs: What we know and understand and what we can do. ASCD Review, 14, 25-31.

Chia, K.H. (2012). Psychogogy. Singapore: Pearson Education.

Code, W., Merchant, S., Maciejewski, W., Thomas, M., & Lo, J. (2016). The Mathematics Attitudes and Perceptions Survey: An instrument to assess expert-like views and dispositions among undergraduate mathematics students. International Journal of Mathematical Education in Science and Technology (21 pages). Retrieved on 14 February, 2020, from: http://dx.doi.org/10.1080/0020739X.2015.1133854.

Cooijmans, P. (n.d.). IQ and real-life functioning. Retrieved 15 February, 2020, from: https://paulcooijmans.com/intelligence/iq_ranges.html.

DB.net (2018) Difference between ability and skill. Retrieved on 29 December, 2019, from: http://www.differencebetween.net/language/difference-between-ability-and-skill/#ixzz5WS3m4ldH.

Dunn, W. (1999). Sensory Profile. San Antonio, CA: The Psychological Corporation.

DuPaul, G.J., Power, T.J., Anastopoulos, A.D., & Reid, R. (1998). ADHD Rating Scale IV: Checklists, norms, and clinical interpretation. New York, NY: Guilford Press.

Flanagan, D.P., & McGrew, K.S. (1997). A cross-battery approach to assessing and interpreting cognitive abilities: Narrowing the gap between practice and cognitive science. In D.P. Flanagan, J. Genshaft, and P.L. Harrison (Eds.), Contemporary intellectual assessment: theories, tests, and issues (Chapter 8). New York, NY: Guilford press.

Flanagan, D.P., Ortiz, S.O., & Alfonso, V.C. (2007). Use of the cross-battery approach in the assessment of diverse individuals. In A.S. Kaufman and N.L. Kaufman (Series Eds.), Essentials of cross-battery assessment second edition (pp.146-205). Hoboken, NJ: John Wiley & Sons.

Gilliam, J.E. (2006). Gilliam Autism Rating Scale (2nd Edition). Austin, TX: Pro-Ed.

Harrier, L.K., & DeOrnellas, K. (2005). Performance of children diagnosed with attention deficit/hyperactivity disorder on selected planning and reconstitution tests. Applied Neuropsychology, 12 (2), 106-119.

Julita (2011) Difference Between ability and skill. DifferenceBetween.net. Retrieved on 23 December, 2019, from: http://www.differencebetween.net/language/difference-between-ability-and-skill/.

Kaufman, A.S. (1994). Intelligence testing with the WISC-III. New York, NY: John Wiley & Sons.

Kennedy, D. (2019). The ADHD symptoms that complicate and exacerbate a math learning disability. Retrieved on 28 December, 2019, from: https://www.additudemag.com/math-learning-disabilities-dyscalculia-adhd/?utm_source=eletter&utm_medium=email&utm_campaign=treatment_january_2020&utm_content=010220&goal=0_d9446392d6-793865f9f5-297687009.

Kulm, G. (1980). Research on mathematics attitude. In J. Shumway (Ed.), Research in mathematics education (pp.356-387). Reston, VA: The National Council of Teachers of Mathematics, Inc.

Low, K. (2016). The challenges of building math skills with ADHD. Retrieved on 12 February, 2020, from: https://www.verywellmind.com/adhd-and-math-skills-20804.

Newman, R.M. (1998). Gifted and math learning disabled. Retrieved on 16 December, 2019, from: http://www.dyscalculia.org/EDu561.html.

Newman, R.M. (1999). The dyscalculia syndrome. Retrieved on 16 December, 2019, from: http://www.dyscalculia.org/thesis.html.

Pearson, N.A., Patton, J.R., & Mruzek, D.W. (2006). Adaptive Behavior Diagnostic Scale. Austin, TX: Pro-Ed.

Renfrew, C. (2019). Renfrew Language Scales (5th Ed.). London, UK: Routledge (Taylor & Francis).

Riccio, C.A., Cohen, M.J., Hall, J., & Ross, C.M. (1997). The third and fourth factors of the WISC-III: What they don’t measure. Journal of Psychoeducational Assessment, 15, 27-39.

Rosenfeld, C. (2019). ADHD and math: 3 struggles for students with ADHD (and how to help). Retrieved 14 December, 2019, from: https://www.ectutoring.com/adhd-and-math.

Sandhu, I.K. (2019). The Wechsler Intelligence Scale for Children-Fourth Edition (WISC–IV). Retrieved on 19 December, 2019, from: http://www.brainy-child.com/expert/WISC_IV.shtml.

Sattler, J.M. (1982). Assessment of children's intelligence and special abilities (2nd ed.). Boston, MA: Allyn & Bacon.

Watkins, M.W., Kush, J.C., & Glutting, J.J. (1997). Discriminant and predictive validity of the WISC-III ACID profile among children with learning disabilities. Psychology in the Schools, 34, 309-319.

Wechsler, D. (2003). The Wechsler Intelligence Scale for Children (4th ed.): Examiner’s manual, San Antonio, TX: The Psychological Corporation.

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Attention-Deficit / Hyperactivity Disorder (ADHD) in Children

What is adhd in children.

Attention-deficit/hyperactivity disorder (ADHD) is a brain-based, or neurodevelopmental, 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 with this type is impulsive and hyperactive. They also have trouble paying attention and are easily distracted.

ADHD, impulsive/hyperactive.  This is the least common type of ADHD. A child with this type is impulsive and hyperactive. But they don't have trouble paying attention.

ADHD, inattentive and distractable.  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's genetic. It's 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. They 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 their 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's 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

Keep in mind that many of these symptoms may happen in children and teens who don’t have ADHD. A key part of diagnosis is that the symptoms must greatly affect how the child functions at home and in school. Make sure your child sees their 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, they will talk with parents and teachers and watch the child. 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 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. ADHD 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 schoolwork.

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

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 severe the symptoms of ADHD are.

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 with ADHD may be helpful.

Key points about ADHD in children

ADHD is often first diagnosed in childhood. A child with ADHD may have trouble paying attention. They 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 healthcare 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.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child’s healthcare provider after office hours. This is important if your child becomes ill and you have questions or need advice

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Attention Deficit Hyperactivity Disorder (ADHD) in a Child Case Study

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A child counselor works with children to help them become mentally and emotionally stable. The case that is examined in this essay is a child with attention deficit hyperactivity disorder (ADHD). The disorder is about disruptive behaviors of children, such as difficulty in communication, aggressiveness, not obeying school or parents’ commands, etc. The child is 12 years old and was diagnosed with ADHD when he was six years old. Numerous complaints from teachers and others around him were due to his disrespectful actions towards them. He does not get well at home or in school and does not listen to anybody. The child has a lot of siblings and a family that is in a financial state of poverty. His parents do not discipline him and place the responsibility of his actions on ADHD. The child usually causes trouble when he is not monitored.

I will use a cognitive theory of counseling to maintain the mental health of the child. The cognitive theory emphasizes an individual’s feelings and present behaviors. It is also more oriented to problem-solving rather than the past of the individual. To communicate with the child and know him better, I will apply “play therapy.” During the therapy, children are expected to play games with different toys that they enjoy. Such activity may reveal various aspects of a child’s personality and mental health. In addition, a counselor can engage more with a child, so having a connection with him. Nielsen et al. (2017) investigated that occupational therapy that includes “play, sensory, motor, and cognitive skills” have a positive impact on children with ADHD (pp. 73). When having play therapy, the child obtains all the attention of a counselor and has the ability to communicate with the adult nearby. Such a comfortable place may make the child feel safe so that he is ready for examination by a counselor.

Moreover, a study of 40 preschool and school-age children with ADHD and their parents and teachers was conducted to examine the effects of play therapy on stabilizing attention deficient hyperactivity disorder (El-Nagger et al., 2017). The study found a positive correlation between the therapy and children’s mental health. There also were significant statistical differences in children’s emotional and behavioral conditions before and after the use of play therapy sessions.

In addition to the play therapy, I suggest using therapy with the child’s parents. Parents-child interactions are shown to be effective in mitigating the disruptive behavior of children (Hosogane et al., 2018). Parents may be involved after an individual therapy session with a counselor. This is because the child may feel aggression towards his parents and be triggered by them. Therefore, careful engagement of parents in game therapy is crucial. By systematic work with parents and the child, a counselor can identify effective treatment and teach parents how to deal with their child outside of a counseling center.

To conclude, the role of a child’s counselor in maintaining the mental health of a child is vital, as he reveals problems of the child and helps him to control his emotions. Play therapy can be applied to work with attention deficit hyperactivity disorder. By active interaction with a child and providing him a comfortable place, a counselor can analyze the actions of the child and suggest treatment. Moreover, there is a need to encourage parents in play therapy to have a persistent treatment.

Nielsen, S. K., Kelsch, K., & Miller, K. (2017). Occupational therapy interventions for children with attention deficit hyperactivity disorder: A systematic review. Occupational Therapy in Mental Health, 33(1), 70-80.

Hosogane, N., Kodaira, M., Kihara, N., Saito, K., & Kamo, T. (2018). Parent–child interaction therapy (PCIT) for young children with attention-deficit hyperactivity disorder (ADHD) in Japan . Annals of General Psychiatry , 17(1), 1-7.

El-Nagger, N. S., Abo-Elmagd, M. H., & Ahmed, H. I. (2017). Effect of applying play therapy on children with attention deficit hyperactivity disorder. Journal of Nursing Education and Practice , 7(5), 104.

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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

Faculty and Disclosures

Disclosure of conflicts of interest, disclosure of unlabeled use.

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.

• Policy Statement for Documentation of Attention-Deficit/Hyperactivity Disorder in Adolescents and Adults (Revised). Princeton, NJ: Office of Disability Policy, Educational Testing Service; June 1999.
• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV). Washington, DC: APA, 2000.
• Dulcan MK, Benson RS. AACAP Official Action. Summary of the practice parameters for the assessment and treatment of children, adolescents, and adults with ADHD. J Am Acad Child Adolesc Psychiatry. 1997;36:1311-7.
• Elia J, Ambrosini PJ, Rapoport JL. Treatment of attention-deficit-hyperactivity disorder. N Engl J Med. 1999;340:780-8.
• Wender PH. Pharmacotherapy of attention-deficit/hyperactivity disorder in adults. J Clin Psychiatry. 1998;59 Suppl 7:76-9.
• Wilens TE, Biederman J, Lerner M; et al. Effects of once-daily osmotic-release methylphenidate on blood pressure and heart rate in children with attention-deficit/hyperactivity disorder: results from a one-year follow-up study. J Clin Psychopharmacol. 2004;24:36-41.
• Searight HR, Burke JM, Rottnek F. Adult ADHD: evaluation and treatment in family medicine. Am Fam Physician. 2000;62:2077-86, 2091-2.
• Biederman J, Faraone SV, Monuteaux MC, et al. Growth deficits and attention-deficit/hyperactivity disorder revisited: Impact of gender, development, and treatment. Pediatrics. 2003;111:1010-6.
• Spencer T, Biederman J, Wilens T. Growth deficits in children with attention deficit hyperactivity disorder. Pediatrics. 1998;102:501-6.
• Spencer T, Biederman J, Harding M, et al. Growth deficits in ADHD children revisited: evidence for disorder-associated growth delays? J Am Acad Child Adolesc Psychiatry. 1996;35:1460-9.
• Hechtman L, Greenfield B. Long-term use of stimulants in children with attention deficit hyperactivity disorder: safety, efficacy, and long-term outcome. Paediatr Drugs. 2003;5:787-94.
• Spencer T, Biederman, M, Coffey B, et al. The 4-year course of tic disorders in boys with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56:842-7.
• Biederman J, Faraone SV, Spencer T. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics. 1999;104:e20.
• Biederman J, Willens TE, Mick E, et al. Does attention-deficit hyperactivity disorder impact the developmental course of drug and alcohol abuse and dependence? Biol Psychiatry. 1998;44:269-73.
• Greene RW, Biederman J, Faraone SV, et al. Adolescent outcome of boys with attention-deficit/hyperactivity disorder and social disability: results from a 4-year longitudinal follow-up study. J Consult Clin Psychol. 1997;65:758-67.
• Wilens TE, Biederman J, Mick E, et al. Attention deficit hyperactivity disorder (ADHD) is associated with early onset substance use disorders. J Nerv Ment Dis. 1997 Aug;185:475-82.
• Clure C, Brady KT, Saladin ME, et al. Attention-deficit/hyperactivity disorder and substance use: symptom pattern and drug choice. Am J Drug Alcohol Abuse. 1999;25:441-8.
• Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit/hyperactivity disorder: a meta-analysis of follow-up studies. Psychological Medicine. In press.
• Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the national comorbidity survey replication. Am J Psychiatry. In press.
• Biederman J, Faraone SV, Mick E, et al. Clinical correlates of ADHD in females: findings from a large group of girls ascertained from pediatric and psychiatric referral sources. J Am Acad Child Adolesc Psychiatry. 1999;38:966-75.
• Weiss G, Hechtman L. Adult hyperactive subjects' view of their treatment in childhood and adolescence. In: G. Weiss and L. Hechtman, eds. Hyperactive Children Grown Up: ADHD in Children, Adolescents, and Adulthood, 2nd ed. New York, NY: The Guilford Press; 1993.
• Mannuzza S, Klein RG, Bessler A, et al. Adult outcome of hyperactive boys: educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry. 1993;50:565-76.
• Biederman J. Impact of Comorbidity in Adults with ADHD. J Clin Psychiatry. 2004(Suppl 3);65:3-7.
• Murphy K, Barkley RA. Attention deficit hyperactivity disorder adults: comorbidities and adaptive impairments. Compr Psychiatry. 1996;37:393-401.
• Biederman J, Faraone SV, Spencer T, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150:1792-8.
• Shekim WO, Asarnow RF, Hess E, et al. A clinical and demographic profile of a sample of adults with attention deficit hyperactivity disorder, residual state. Compr Psychiatry. 1990;31:416-25.
• Hornig M. Addressing comorbidity in adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry. 1998;59:769-75.
• Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 1999;40:57-87.
• Pliszka SR, Carlson CL, Swanson JM. ADHD With Comorbid Disorders: Clinical Assessment and Management. New York, NY: The Guilford Press; 1999.

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.  

Ready to Make a Change?

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.