ADHD With Comorbid Disorders: Clinical Assessment and Management

Comorbidity in psychiatric disorders has been a major concern because it influences clinical management and course and may have etiological implications. This text reviews the literature on comorbidity in attention deficit hyperactivity disorder (ADHD) and how it affects clinical decisions. It identifies problems of differential diagnosis and systematically reviews the evidence for specific patterns of psychopharmacological treatment, as well as family history, for ADHD that is comorbid with various disorders. It also identifies the current controversies and disagreements in the field. On all these counts, the book does a superb job. The overviews are lucid and make for easy, enjoyable reading. The discussions of differential diagnosis and medication management are sensible, provide useful clinical suggestions, and will be of use to any clinician who deals with children who have ADHD.

The title does the book a disservice because the book not only discusses comorbidity but also guides clinicians on the value of different assessments in order to differentiate ADHD from other childhood disorders. As an example, the authors discuss the value (or lack thereof) of cognitive testing for differentiating ADHD from conduct disorder. They also provide comprehensive overviews of drug action and treatment guidelines for ADHD in general. All this is done in a reader-friendly fashion. One senses that the authors not only are scholarly but have much hands-on clinical experience enabling them to walk the reader through thorny clinical problems of differential diagnosis and pharmacotherapy. Pointed clinical case histories bring the issues to life.

In addition to reviewing psychiatric comorbidity in ADHD, which includes important coverage of mental retardation and pervasive developmental disorders, the book also summarizes current knowledge about the role of medical disorders in ADHD. The authors do not hesitate to take a stand, such as noting the weak evidence linking allergies to ADHD, but they do so in a dispassionate, thoughtful manner that promotes an appreciation of uncertainties in the field. Although the diagnostic and psychopharmacological evidence reviewed is data based, it is not dry and can be translated easily into clinical practice. The authors are to be commended for their contribution.

The same cannot be said of the book’s sections on behavioral interventions. These are tacked on to the end of the text and not integrated into the issue of comorbidity. However, behavior management procedures are well described and informative. Unfortunately, the nonspecialist will be misled by the book’s claims of efficacy. The authors report that there is ample evidence that behavioral intervention is effective in ADHD, but they do not substantiate this claim and provide no relevant references. This section stands in marked contrast to the rest of the book, which is meticulous in this regard. The book was published at a time when the results of the large multisite study of medication alone, behavior treatment alone, and medication and behavior treatment in combination with medication (1) were known. This study failed to document an advantage for the combination treatment over medication alone and did not support the efficacy of extended, intense, systematic multimodal behavioral treatment in children with ADHD. There is no mention of the trial in the book. It is unfortunate that standards for scholarship and clinical relevance that were applied to the sections on diagnosis, pharmacotherapy, and family history were not applied to the coverage of behavioral management. In every other respect, the book is a wonderful resource to anyone interested in what is known about ADHD.