JOSEPH AUSTERMAN, DO

Center for Pediatric Behavioral Health, Cleveland Clinic Childrens

ADHD and behavioral disorders: Assessment,

management, and an update from DSM-5
ABSTRACT sions since 1994. Among the most clinically relevant
Behavioral disorders in pediatric patientsprimarily changes were revisions to the diagnosis of ADHD and
attention deficit hyperactivity disorder (ADHD)pose a the creation of a new diagnostic entity: disruptive
clinical challenge for health care providers to accurately mood dysregulation disorder (DMDD).
assess, diagnose, and treat. In 2013, updated diagnostic This article focuses on the updated diagnostic cri-
criteria for behavioral disorders were published, includ- teria published in the DSM-5 for behavioral disorders,
ing ADHD and a new diagnostic entity: disruptive describes the assessment of ADHD, and summarizes
mood dysregulation disorder. Revised criteria for ADHD management strategies.
includes oldest age for occurrence of symptoms, need for
symptoms to be present in more than one setting, and UPDATED DIAGNOSTIC CRITERIA
requirement for number of symptoms in those aged 17
ADHD
and older. Assessment of ADHD relies primarily on the
This disorder is a chronic, neurologically based ill-
clinical interview, including the medical and social history,
ness characterized by a persistent pattern of inatten-
along with the aid of objective measures. The clinical
tion and/or hyperactivity and impulsivity that are
course of ADHD is chronic with symptom onset occurring
more inappropriate or disruptive than those in other
well before adolescence. Most patients have symptoms
children of a comparable age resulting in functional
that continue into adolescence, and some into adulthood.
impairment in multiple settings, and these behaviors
Many patients with ADHD have comorbid disorders such
have been present for at least 6 months. Revised diag-
as depression, disruptive behavior disorders, or substance
nostic criteria in DSM-5 used the same two categories
abuse, which need to be addressed first in the treatment
for ADHD symptomsinattention and hyperactiv-
plan. Treatment of ADHD relies on a combination of
ity-impulsive behaviorsbut modified several diag-
psychopharmacologic, academic, and behavioral interven-
nostic requirements.
tions, which produce response rates up to 80%.
Revised criteria

B
ehavioral disorders in pediatric patients Impairment before age 12 instead of age 6. As a neuro-
primarily attention deficit hyperactivity dis- developmental disorder, ADHD usually starts at a
order (ADHD)pose a clinical challenge young age; teenagers presenting with newly devel-
for health care providers to accurately assess, oped ADHD-type symptoms probably do not have
diagnose, and treat. In 2013, the criteria for several ADHD and efforts should be made to rule out other
disruptive behavioral disorders were updated in the illnesses or social dynamics. The DSM-5 raised the
fifth edition of the Diagnostic and Statistical Manual age limit for onset of qualifying symptoms to before
of Mental Disorders (DSM-5),1 their first major revi- 12 years (previously by age 6) primarily to capture
a cohort of pediatric patients, typically female, who
present solely with inattention symptoms and may
Dr. Austerman reported that he has no financial interests or relationships that
pose a potential conflict of interest with this article. not display overt functional impairment early on.
This article was developed from an audio transcript of Dr. Austermans presen- Symptoms required in at least two settings. Symptoms
tation at the Perspectives in Pediatrics: From Theory to Practice symposium must be present in at least two settings to qualify for a
held at the Global Center for Health Innovation, Cleveland, OH, May 810, diagnosis of ADHD. This ensures that the behaviors
2014. The transcript was formatted and edited by Cleveland Clinic Journal of
Medicine staff for clarity and conciseness, and was then reviewed, revised, and occur globally; they do not occur just at school or at
approved by Dr. Austerman. home but occur in both places.
doi:10.3949/ccjm.82.s1.01 Fewer symptoms required for diagnosis in adolescents.
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 AUSTERMAN

Although the diagnostic criteria retain the same are seen in children with intellectual disabilities or an
symptoms as those in DSM-IV for different age autism spectrum disorder.
groups, individuals aged 17 and older are now required
to display only five or more inattentive or hyperac- Disruptive mood dysregulation disorder
tive-impulsive symptoms. Previously, at least six were A new diagnostic category in DSM-5 is termed dis-
required. ruptive mood dysregulation disorder (DMDD). This
captures many children who previously would have
Partial remission criteria been diagnosed with pediatric bipolar disorder, even
The concept of partial remission was introduced in though most of them do not fulfill criteria for bipolar
DSM-5. This acknowledges that two-thirds of chil- disorder as adults. The presence of baseline irritabil-
dren diagnosed with ADHD do not have symptoms ity separates this disorder from IED, which requires
that functionally impact activities of daily living intermittent rapid and severe outbursts. The severe
beyond age 18. temper outbursts of DMDD must be recurrent, with
Oppositional defiant disorder an average of three occurrences per week, and have
In DSM-5, oppositional defiant disorder (ODD) background irritability. The symptoms must have a
is defined by emotional and behavioral symptoms duration of at least 12 months and be present in two
grouped into three categories: settings. A diagnosis of DMDD cannot be made ear-
Constant anger or irritability lier than age 6, with onset before age 10.
Argumentative or defiant behavior (arguing
with authority figures) ASSESSMENT OF ADHD
Vindictiveness. The clinical interview in conjunction with objective
Because defiant behavior may represent difficulty scales is the primary tool for diagnosing ADHD. The
with self-control, ODD is associated with execu- most frequent source of information is from the par-
tive functioning deficits that are present in ADHD. ents followed by the childs schoolteachers. Patient
Children with ODD tend to perform best in situa- interview, although unreliable in young children,
tions in which they can dominate or exert authority. should also be part of the assessment. Comparing the
To qualify as ODD, the pattern of behavior must be patients functional impairment against children of a
consistent for longer than 6 months. A severity rating similar age is necessary for an ADHD diagnosis.
was added based on pervasiveness of ODD symptoms. The medical history can help rule out children with
Otherwise the diagnosis did not change. asthma or allergy being treated with corticosteroids
Conduct disorder: Purposeful aggression and those with hypothyroidism and hyperthyroidism
The hallmarks of conduct disorder are purposeful whose symptoms often fulfill the diagnostic criteria
aggression (eg, bullying), destruction of property, for ADHD.2,3 Symptoms of ADHD also may appear
deceitfulness or theft, and serious violation of rules suddenly after a traumatic brain injury or other neuro-
(eg, running away from home, repeat truancy). Some logic event.4 Other psychiatric illnesses, especially
consider conduct disorder to be a separate illness learning disorders, mood disorders, anxiety, other
from ODD, whereas others consider it a continuum disruptive behavior disorders, or substance abuse, can
of the same disorder. Conduct disorder can manifest mimic ADHD.
as violence, as in initiating physical fights, or it can Ruling out other factors from a social history (eg,
manifest in behaviors such as truancy, stealing, lying, family conflict, bullying, sleep deprivation, being
and running away from home without the physical- overscheduled with activities) adds to the reliabil-
aggression aspect. ity of an ADHD diagnosis. For example, repetitive
uprooting and frequent changes in schools can cause
Intermittent explosive disorder academic problems that may be mistaken for ADHD,
Failure to control aggressive impulses defines inter- and use of stimulants may have failed to improve
mittent explosive disorder (IED). The aggressive symptoms in these children.
outbursts can be verbal or behavioral and tend to be
impulsive. A small subset of children display isolated Assessment scales
aggression out of proportion to provocation. The dis- Pediatric assessment scales that can be performed in
order tends to manifest at ages 3 or 4, and a diagnosis an office are more practical than standardized clinical
requires a stable environment with no significant assessments (Table 1). The Vanderbilt ADHD Diag-
early childhood trauma. Most often these symptoms nostic Teacher Rating Scale correlates highly with a
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ADHD AND BEHAVIORAL DISORDERS

TABLE 1
Selected diagnostic tools for ADHD assessment

Scale or test Notes and resources

Vanderbilt ADHD Diagnostic Teacher Rating Scale http://www.nichq.org/childrens-health/adhd/resources/vanderbilt-
assessment-scales
Vanderbilt ADHD Diagnostic Parent Rating Scale http://www.nichq.org/childrens-health/adhd/resources/vanderbilt-
assessment-scales
Conners, Third Edition http://www.mhs.com/product.aspx?gr=cli&id=overview&prod=conners3
Successor to Conners Rating ScalesRevised (CRSR)
Diagnostic Interview for Children and Adolescents (DICA-IV) http://www.mhs.com/product.aspx?gr=edu&id=overview&prod=dicaiv
Based on DSM-IV criteria
Schedule for Affective Disorders and Schizophrenia in School- http://bit.ly/K-SADS-PL_inst
Age ChildrenPresent and Lifetime Version (K-SADS-PL) DSM-III-R and DSM-IV criteria

diagnosis of ADHD. We use the Vanderbilt ADHD delinquency and peer rejection are high. This may
Diagnostic Parent Rating Scale for children up to age result in secondary comorbidity such as emotional,
1 year. Other scales track symptoms and functional disruptive, or substance abuse problems.
impairment over time and can be administered before
the patients appointment. The Conners Third Edition MANAGEMENT STRATEGIES
scale can be used to establish a baseline before initiat-
ing therapy and to help monitor changes over time. Stimulants
Standardized tests to bolster the utility of the The first-line pharmacologic treatment of ADHD is
clinical interview include the Diagnostic Interview stimulants: methylphenidate, dexmethylphenidate,
Schedule for Children and Adolescents and the mixed amphetamine salts, dextroamphetamine, and
Schedule for Affective Disorders and Schizophrenia lisdexamfetamine. Head-to-head trials of medications
in School-Age ChildrenPresent and Lifetime Ver- versus behavioral management favor medication use,
sion. Free training is available regarding use of some even over the long term.1214
of these standardized tests. Methylphenidate and amphetamines are equally
effective and have similar adverse effect profiles.
Developmental course, risk factors Insomnia and anorexia are the most common side
The clinical course of ADHD is chronic. The onset of effects of stimulants. Cardiac effects include tachy-
hyperactivity usually occurs at age 3 or 4, with com- cardia, chest pain, and hypertension. Very rarely,
bined hyperactivity and inattention usually appear- stimulants have been associated with sudden cardiac
ing from ages 5 to 8.5,6 The evolution of symptoms death syndrome in patients with underlying cardiac
is progressive and constant. Between 50% and 80% problems. The consensus is that stimulants are safe
have symptoms that continue into adolescence, and in the general population. The need to obtain an
in about 40%, symptoms continue into adulthood.7,8 electrocardiogram before initiating a stimulant was
Some children with ADHD have a temperament- removed by the US Food and Drug Administration
neuropsychological profile characterized by aggres- (FDA) unless it is otherwise indicated.15
siveness, irritability, and mood lability. Deficits in The response rate to stimulants is in the range of
planning, delayed aversion, and temporal processing 70%. About one-third of patients have side effects,
are present. and approximately 15% have side effects severe
Risk factors include prematurity, prenatal com- enough to requiring changing or withdrawing the
plications, an anoxic event, nutritional deficits medication.16,17
(specifically iron and zinc), and lack of appropriate Stimulants are available in several delivery systems.
socialization.911 The disorder is heritable, which For the best effect, medications should be combined
is usually clear from the clinical interview. Rates of with behavioral management.
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TABLE 2 TABLE 3
ADHD comorbidities23,24 Summary of drug therapy options for ADHD
with comorbidities
Comorbidity Rates
Oppositional defiant disorder 54%67% ADHD + oppositional defiant disorder or conduct disorder
Conduct disorder 26% Stimulant or atomoxetine plus behavioral therapy
Mood disorders 20%30% Stimulants + behavioral therapy + alpha agonist
Substance abuse 12%24% Stimulants + behavioral therapy + second-generation antipsychotic
Anxiety disorders 10%40%
Tic disorders 18% ADHD + mood disorders
Bipolar disorder
Second-generation antipsychotic; then add stimulant
Atomoxetine, alpha agonist, or bupropion
Alternatives to stimulants Major depressive disorder
If stimulants are ineffective, atomoxetine can be used Bupropion; then add stimulant
to treat patients with inattention; however, its effect Selective serotonin reuptake inhibitor + stimulant
on hyperactivity and impulsivity is less pronounced Cognitive behavior therapy + atomoxetine + alpha agonist
than that of stimulants. Bupropion is another option
for inattention. Both agents are well tolerated. Irrita- ADHD + substance abuse
bility and insomnia are side effects of atomoxetine,
Atomoxetine
and liver damage is possible, so liver function tests
Bupropion
must be ordered if the patient complains of upper-
right-quadrant pain. Alpha agonist
The evidence to support the use of modafinil is Stimulant difficult to abuse (eg, lisdexamfetamine)
equivocal.18,19 Unlike stimulants, modafinil is associ-
ated with a slight increase in motivation. ADHD + anxiety
Alpha-2 agonists are effective for treating aggres- Atomoxetine
sion in the setting of ADHD, especially in younger Selective serotonin reuptake inhibitor + stimulant or alpha agonist
children, and are well tolerated.20 Extended-release + cognitive therapy
forms are available. Tricyclic antidepressants (for pediatric anxiety)

Combination therapy
ADHD + tics
Polypharmacy is sometimes indicated in the treat-
ment of ADHD. A stimulant used in combination Alpha-2 antagonists
with atomoxetine was shown to be superior to either Atomoxetine
treatment alone in improving symptoms of hyperac-
tivity and inattention.21 The combination, however,
markedly increased the incidence of appetite loss,
insomnia, and irritability. oping a treatment strategy. The following describes
A more promising combination is a stimulant with treatment options for the most common ADHD
an alpha agonist. Symptoms of hyperactivity and comorbidities (Table 3).
inattention were improved more with this combina- ODD or conduct disorder. The first-line therapy for
tion than with a stimulant plus placebo, with no dif- these patients is a stimulant plus behavioral therapy.
ference in side effects.22 Adding an alpha agonist to this combination may be
indicated if the comorbidity is severe. Second-gener-
ADHD with comorbidities ation antipsychotics also have been used as add-ons
Patients with ADHD, both adults and children, often to stimulants with behavioral therapy, but weight
have comorbid externalizing disorders and other gain and hormonal side effects are common.
emotional disorders, such as depression and anxiety, Behavioral interventions are effective in targeting
occurring in up to half of cases (Table 2).23,24 These disruptive behavioral disorders, specifically multi-
comorbidities are important to consider when devel- systemic therapy. Multisystemic therapy is intensive
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ADHD AND BEHAVIORAL DISORDERS

therapy that involves working with the patients term reduction of core symptoms of ADHD.31,32 No
peer group or school, but most children must enter herbal remedy has demonstrated efficacy in improv-
the legal system to receive this intervention. Multi- ing ADHD symptoms. The use of omega-3 fatty acids
systemic therapy is the only intervention shown to as a complement to stimulants has demonstrated effi-
improve symptoms associated with comorbid ADHD cacy in reducing core symptoms in ADHD.33
and conduct disorder.25
Mood disorders. For these patients, the mood disor- Behavioral therapy
der is treated first. In doing so, symptoms of ADHD Several forms of behavioral therapy have shown
may disappear. For those with bipolar disease, a utility in improving symptoms in ADHD. Evidence
second-generation antipsychotic agent is superior to supports that ADHD responds to cognitive behav-
lithium in efficacy, maintenance of remission, and side ioral therapy.34 In-school neurofeedback training
effects in patients with a clear bipolar affective disor- for ADHD was shown to be better than cognitive
der, after which a stimulant can be added with less training in improving inattention and hyperactivity-
risk of developing manic symptoms. Using a stimulant impulsivity at 6 months of follow-up.35
first for this indication risks mood destabilization. Parental training has the most evidence to support
For patients with a major depressive disorder, its use in children with ADHD. The two most com-
bupropion can be used, although this indication is mon forms are Pathways Triple P (Positive Parenting
not FDA-approved, followed by the addition of a Program) and The Incredible Years. Triple P is an early
stimulant. One alternative is a selective serotonin intervention designed to promote positive parent-
reuptake inhibitor plus a stimulant; another is cog- child relationships to reduce behavior problems.36
nitive behavioral therapy plus atomoxetine and an The Incredible Years is a multicomponent program
alpha agonist. that emphasizes creating opportunities for active
Substance abuse. Patients with ADHD have high involvement, reinforcement of positive behavior,
rates of substance abuse.26,27 Whether treatment of teaching skills, and setting clear limits, all of which
ADHD with stimulants reduces the risk of substance are central to the social development strategy.37
abuse is controversial. Because abuse of stimulants is Many children with ADHD respond to in-school
common, start treatment with atomoxetine, bupro- interventions, at least an evaluation to rule out learn-
pion, an alpha agonist, or a stimulant that is difficult ing disorders, which typically have high morbidity.
to abuse (eg, lisdexamfetamine). Refer patients who Children may qualify for Individualized Education
are abusing substances to a specialist in substance Program (IEP) services, such as peer tutoring,38 com-
abuse for behavioral management. puter-assisted instruction,39,40 and task-modification
Anxiety. Atomoxetine is recommended for the instruction.41 All of these have evidence to support
treatment of anxiety that coexists with ADHD. A their use.
selective serotonin reuptake inhibitor in combina-
tion with a stimulant or alpha agonist, plus cognitive REFERENCES
behavioral therapy, is another option for treating 1. American Psychiatric Association. Diagnostic and Statistical
anxiety and ADHD. Tricyclic antidepressants have Manual of Mental Disorders. 5th ed. Arlington, VA: American
shown benefit in pediatric anxiety. Bupropion should Psychiatric Association; 2013.
2. Hak E, de Vries TW, Hoekstra PJ, Jick SS. Association of child-
not be used to target anxiety as it has been shown to hood attention-deficit/hyperactivity disorder with atopic diseases
have a limited effect on anxiety. and skin infections? A matched case-control study using the Gen-
Tics. Stimulants may transiently exacerbate under- eral Practice Research Database. Ann Allergy Asthma Immunol
2013; 111:102106.
lying tic disorders, but no longstanding difference 3. Pretorius E. Corticosteroids, depression and the role of serotonin.
in the course of tics has been observed with stimu- Rev Neurosci 2004; 15:109116.
lant use.28 Alpha-2 antagonists target both tics and 4. Keenan HT, Hall GC, Marshall SW. Early head injury and atten-
tion deficit hyperactivity disorder: retrospective cohort study. BMJ
ADHD, so their use is preferred.29 Atomoxetine does 2008; 337:a1984.
not exacerbate tics but may reduce their frequency 5. Applegate B, Lahey BB, Hart EL, et al. Validity of the age-of-onset
and severity.30 criterion for ADHD: a report of the DSM-IV field trials. J Am Acad
Child Adolesc Psychiatry 1997; 36:12111221.
6. Loeber R, Green SM, Lahey BB, Christ MAG, Frick PJ. Devel-
Dietary factors opmental sequences in the age of onset of disruptive child behav-
Although challenging to accomplish, management iors. J Child Fam Studies 1992; 1:2141.
of diet, specifically removal of artificial food coloring 7. Barkley RA, Murphy KR, Fischer M. Adult ADHD: What the
Science Says. New York, NY: Guilford Publications; 2008.
and sodium benzoate preservatives, has been more 8. Rasmussen P, Gillberg C. Natural outcome of ADHD with
efficacious than behavioral management in the long- developmental coordination disorder at age 22 years: a controlled,

S6 C L E V E L A N D C L INI C J OURNAL OF ME DI CI NE VOLUME 82 SUPPLEMENT 1 NOV EMBER 2015

 AUSTERMAN

longitudinal, community-based study. J Am Acad Child Adolesc 18:556559.

Psychiatry 2000; 39:14241431. 26. Wilens TE, Martelon M, Joshi G, et al. Does ADHD predict
9. Silva D, Colvin L, Hagemann E, Bower C. Environmental risk substance-use disorders? A 10-year follow-up study of young
factors by gender associated with attention-deficit/hyperactivity adults with ADHD. J Am Acad Child Adolesc Psychiatry 2011;
disorder. Pediatrics 2014; 133:e14e22. 50:543553.
10. Lindstrm K, Lindblad F, Hjern A. Preterm birth and attention- 27. Charach A, Yeung E, Climans T, Lillie E. Childhood attention-
deficit/hyperactivity disorder in schoolchildren. Pediatrics 2011; deficit/hyperactivity disorder and future substance use disorders:
127:858865. comparative meta-analyses. J Am Acad Child Adolesc Psychiatry
11. Banerjee TD, Middleton F, Faraone SV. Environmental risk fac- 2011; 50:921.
tors for attention-deficit hyperactivity disorder. Acta Paediatr 2007; 28. Spencer T, Biederman J, Wilens T, et al. Efficacy of a mixed
96:12691274. amphetamine salts compound in adults with attention-deficit/
12. Brown RT, Amler RW, Freeman WS, et al; for the American hyperactivity disorder. Arch Gen Psychiatry 2001; 58:775782.
Academy of Pediatrics Committee on Quality Improvement; 29. Weisman H, Qureshi IA, Leckman JF, Scahill L, Bloch MH.
American Academy of Pediatrics Subcommittee on Attention- Systematic review: pharmacological treatment of tic disorders
Deficit/Hyperactivity Disorder. Treatment of attention-deficit/ efficacy of antipsychotic and alpha-2 adrenergic agonist agents.
hyperactivity disorder: overview of the evidence. Pediatrics 2005; Neurosci Biobehav Rev 2013; 37:11621171.
115:e749e757. 30. Allen AJ, Kurlan RM, Gilbert DL, et al. Atomoxetine treatment
13. The MTA Cooperative Group. A 14-month randomized clinical in children and adolescents with ADHD and comorbid tic disorders.
trial of treatment strategies for attention-deficit/hyperactivity disor- Neurology 2005; 65:19411949.
der. Arch Gen Psychiatry 1999; 56:10731086. 31. McCann D, Barrett A, Cooper A, et al. Food additives and hyper-
14. MTA Cooperative Group. National Institute of Mental Health active behaviour in 3-year-old and 8/9-year-old children in the
Multimodal Treatment Study of ADHD follow-up: 24-month community: a randomised, double-blinded, placebo-controlled trial.
outcomes of treatment strategies for attention-deficit/hyperactivity Lancet 2007; 370:15601567.
disorder. Pediatrics 2004; 113:754761. 32. Schab DW, Trinh NH. Do artificial food colors promote hyperac-
15. Martinez-Raga J, Knecht C, Szerman N, Martinez MI. Risk of tivity in children with hyperactive syndromes? A meta-analysis of
serious cardiovascular problems with medications for attention- double-blind placebo-controlled trials. J Dev Behav Pediatr 2004;
deficit hyperactivity disorder. CNS Drugs 2013; 27:1530. 25:423434.
16. Barbaresi WJ, Katusic SK, Colligan RC, Weaver AL, Leibson 33. Freeman MP, Hibbeln JR, Wisner KL, et al. Omega-3 fatty acids:
CL, Jacobsen SJ. Long-term stimulant medication treatment of evidence basis for treatment and future research in psychiatry. J Clin
attention-deficit/hyperactivity disorder: results from a population- Psychiatry 2006; 67:19541967.
based study. J Dev Behav Pediatr 2006; 27:110. 34. Muoz-Solomando A, Kendall T, Whittington CJ. Cognitive
17. Schachter HM, Pham B, King J, Langford S, Moher D. How effi- behavioural therapy for children and adolescents. Curr Opin Psy-
cacious and safe is short-acting methylphenidate for the treatment chiatry 2008; 21:332337.
of attention-deficit disorder in children and adolescents? A meta- 35. Steiner NJ, Frenette EC, Rene KM, Brennan RT, Perrin EC. In-
analysis. CMAJ 2001; 165:14751488. school neurofeedback training for ADHD: sustained improvements
18. Biederman J, Pliszka SR. Modafinil improves symptoms of atten- from a randomized control trial. Pediatrics 2014; 133:483492.
tion-deficit/hyperactivity disorder across subtypes in children and 36. Wiggins TL, Sofronoff K, Sanders MR. Pathways Triple P-positive
adolescents. J Pediatr 2008; 152:394399. parenting program: effects on parent-child relationships and child
19. Taylor FB, Russo J. Efficacy of modafinil compared to dextroam- behavior problems. Fam Process 2009; 48:517530.
phetamine for the treatment of attention deficit hyperactivity disor- 37. Haggerty KP, McGlynn-Wright A, Klima T. Promising parenting
der in adults. J Child Adolesc Psychopharmacol 2000; 10:311320. programs for reducing adolescent problem behaviors. J Child Serv
20. Hirota T, Schwartz S, Correll CU. Alpha-2 agonists for atten- 2013; 8(4).
tion-deficit/hyperactivity disorder in youth: a systematic review 38. Greenwood CR. Longitudinal analysis of time, engagement, and
and meta-analysis of monotherapy and add-on trials to stimulant achievement in at-risk versus non-risk students. Except Child 1991;
therapy. J Am Acad Child Adolesc Psychiatry 2014; 53:153173. 57:521535.
21. Wilens TE. Combined pharmacotherapy in pediatric psychophar- 39. Mautone JA, DuPaul GJ, Jitendra AK. The effects of computer-
macology: friend or foe? J Child Adolesc Psychopharmacol 2009; assisted instruction on the mathematics performance and classroom
19:483484. behavior of children with ADHD. J Atten Disord 2005; 9:301312.
22. Wilens TE, Bukstein O, Brams M, et al. A controlled trial of 40. Rabiner DL, Murray DW, Skinner AT, Malone PS. A random-
extended-release guanfacine and psychostimulants for attention- ized trial of two promising computer-based interventions for stu-
deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry dents with attention difficulties. J Abnorm Child Psychol 2010;
2012; 51:7485.e2. 38:131142.
23. Michielsen M, Comijs HC, Semeijn EJ, Beekman ATF, Deeg 41. Dunlap G, dePerczel M, Clarke S, et al. Choice making to pro-
DJH, Kooij JJS. The comorbidity of anxiety and depressive symp- mote adaptive behavior for students with emotional and behavioral
toms in older adults with attention-deficit/hyperactivity disorder: a challenges. J Appl Behav Anal 1994; 27:505518.
longitudinal study. J Affect Disord 2013; 148:220227.
24. Jensen PS, Hinshaw SP, Kraemer HC, et al. ADHD comorbidity
findings from the MTA study: comparing comorbid subgroups. J Am
Acad Child Adolesc Psychiatry 2001; 40:147158. Correspondence: Joseph Austerman, DO, Center for Pediatric Behavioral
25. Hazell P. Review of attention-deficit/hyperactivity disorder comor- Health, Cleveland Clinic Childrens, 9500 Euclid Avenue, P57, Cleveland, OH
bid with oppositional defiant disorder. Australas Psychiatry 2010; 44195; austerj@ccf.org

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