No material available at www.caddra.ca (the "Materials") may be copied, reproduced, republished, uploaded, posted, transmitted, or distributed in any way, except that you may: (a) Download one copy of the Materials on any single computer for your personal or medical practice use only, provided you keep intact all copyright and other proprietary notices. Where stipulated, specific "tools and patient handouts", developed for physicians and other medical professionals to use in their practice, may be reproduced by medical professionals or on the advice of medical professionals; (b) Give a presentation using the Materials, so long as: (i) the purpose of the presentation or distribution is for public education; (ii) you keep intact all copyright and other proprietary notices in the Materials; and (iii) the presentation or distribution is completely noncommercial and you or your organization receive no monetary compensation. If monetary compensation is involved, you must provide notice to CADDRA at least ten (10) business days before the presentation and request permission. Modification of the Materials or use of the Materials for any other purpose, without the prior written consent of CADDRA, is a violation of CADDRA's copyright and other proprietary rights.# Contents of CADDRA ADHD ASSESSMENT eTOOLKIT (USB key)
Step 

# PREFACE

# CANADIAN ADHD PRACTICE GUIDELINES INTRODUCTION
The purpose of the Canadian ADHD Practice Guidelines is to improve the quality of health care and outcomes for all individuals with Attention Deficit Hyperactivity Disorder (ADHD) in Canada.
The Guidelines:
- Cover the lifespan of the disorder.
- Are based on published evidence.
- Involve expert consensus when evidence is lacking.
- Offer practical clinical advice.
- Provide assessment, treatment and follow-up questionnaires.
- Include templates for requesting accommodations.
- Recommend optimizing care on an individual basis.
- Assist healthcare providers to empower their patients to make informed choices in a collaborative process of care.
- Contain information specific to the Canadian healthcare system.
The Guidelines are targeted at health care professionals but may also be of use to additional stakeholders (policy makers, funding bodies, educators) and individuals with ADHD and their families. The tools included in the Guidelines were selected based on their validity, reliability and accessibility. These Guidelines were developed to provide information and user-friendly tools to support Canadian health care professionals in diagnosing and treating ADHD across the lifespan. These Guidelines are not intended to replicate or replace the many excellent textbooks on ADHD.

# The evolution of the 4th Edition
The Canadian ADHD Practice Guidelines are produced and funded by CADDRA -Canadian ADHD Resource Alliance, a national, independent, not-for-profit association whose members are drawn from family practice, pediatrics, psychiatry (child, adolescent and adult), psychology and other health professions.

# The Guidelines have been in constant review for over ten years
The fourth edition of the Canadian ADHD Practice Guidelines evolved from earlier editions published in 2006, 2008, and 2011. A multidisciplinary team that included ADHD specialists, pediatricians, psychiatrists, psychologists, family physicians, pharmacists, nurses, educators and community stakeholders from across Canada and from the US contributed to its writing and review.

# Disclosures and Funding
Conflicts of interest were recorded for all individuals that were a part of the process and are included in the Guidelines. As has been the case since the 1 st edition of the Canadian ADHD Guidelines, all authors have donated their time and shared their expertise without receiving any financial contribution. The final draft of the 4th edition was independently reviewed by a range of relevant stakeholders (e.g., adult psychiatrist, child and adolescent psychiatrist, psychologist, patient advocate/nurse, family physician). The Guidelines development process was fully funded by CADDRA and occurred without external financial grants.

# Endorsements
These Guidelines are endorsed by the Centre for ADHD Awareness, Canada (CADDAC).

# CADDRA GUIDELINES -CORE PRINCIPLES
These Guiding Principles were developed and approved by the CADDRA Board.

# Principles for Assessment and Diagnosis
- The clinician has to be fully licensed and adequately trained in order to ensure Diagnostic and Statistical Manual, Fifth Edition (DSM-5) diagnostic criteria for ADHD are fully met . 2. The assessment needs to reflect an understanding of multi-systemic issues that may confound or complicate the ADHD diagnosis (e.g., the educational/vocational, psychosocial, psychiatric and medical interfaces). 3. Symptoms and functional impairment need to be assessed. Using valid, reliable and sensitive instruments helps to evaluate frequency, severity, and outcome. 4. Regular documentation of symptoms and functional impairment, if possible at each visit, helps to track progress and monitor outcome. 5. Establishing collaborative treatment goals with the patient (and their family when appropriate) ensures that outcomes are patient-centered. 6. The results of the assessment need to be communicated to the patient and their family with clarity and compassion. 

# Acronyms

# ADHD

# CHAPTER 1: DIAGNOSIS OF ADHD
Attention Deficit Hyperactivity Disorder (ADHD) is typically a chronic, often lifelong, condition. The impact and presentation of ADHD can change over time  and often requires lifelong monitoring and treatment . Clinicians who follow individual patients and their families should be knowledgeable about how ADHD presents and causes functional impairment across the lifespan.
Although the term Attention Deficit Disorder was first introduced in 1980 in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) , symptoms of inattention, hyperactivity and impulsivity have been described in children over the last 200 years . A historical perspective reveals that Melchior Adam Weikard is credited with first describing a disorder similar to ADHD in 1775 , followed by Sir Alexander Crichton's description in 1798 ; Heinrich Hoffman M.D. created the character of "Fidgety Phil", used as a popular allegory for children with ADHD, in 1844 ; and Dr. George Frederic Still described a condition remarkably similar to ADHD in the English medical journal the Lancet in 1902 . In 1937, psychiatrist Charles Bradley administered Benzedrine sulfate, an amphetamine, to "problem" children at a home in Providence, Rhode Island to alleviate headaches but noticed an unexpected behavioural effect: improved school performance, social interactions, and emotional responses .
The Diagnostic and Statistical Manual of Mental Disorders, Second edition (DSM-II) described the disorder "hyperkinetic reaction of childhood (or adolescence)" in 1968 .
ADHD is now defined as a neurodevelopmental disorder. Characterization of ADHD has evolved through several revisions over the years, the most recent one being in the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) in 2013 . ADHD is usually seen in early childhood, but not necessarily diagnosed at that time. It is thought to be a lifelong disorder. More than 50% of individuals diagnosed in childhood and adolescence continue to have significant and impairing symptoms in adult life .
The general prevalence of ADHD is estimated at between 5-9% for children and adolescents and 3-5% for adults . The disorder is not confined to the USA or Canada but is prevalent worldwide .
There is a common public misconception, reinforced by much of the media, that ADHD is over-diagnosed. However, a recent meta-analysis confirmed stable rates of the prevalence of ADHD over the past 30 years .
The etiology of ADHD remains under investigation. ADHD is highly heritable . Parents with ADHD have a better than 50% chance of having a child with ADHD, and about 25% of children with ADHD have parents who meet the formal diagnostic criteria for ADHD . Twin studies have placed the heritability of ADHD at 76%  with the risk of ADHD in first-degree relatives of diagnosed individuals being somewhere between 30 to 40% . This includes children of adults with ADHD, their siblings or their parents.
The genetics of ADHD are complex . Many different genes have been identified as linked to ADHD (DRD4, DAT) but, as ADHD is a heterogeneous disorder, it is most likely related to complex genetic etiologies .
The ongoing genome wide studies are likely to shed light on this issue in the future . Other etiological factors have been linked to ADHD, such as tobacco/alcohol use during pregnancy. Low birth weight and psychosocial adversity should be considered as possible contributors to ADHD symptomatology in an individual . Neuronal networks associated with ADHD have been reviewed in neuroimaging studies and the dysfunction of fronto-striatal pathways (dorsolateral and anterior cingulate) is often targeted as a possible underlying neural mechanism . A landmark study on ADHD, the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study , found that 70% of school-aged children with ADHD have at least one other psychiatric disorder such as anxiety, Oppositional Defiant Disorder, Obsessive Compulsive Disorder, Tic Disorder or depression.

# Making a Diagnosis in Primary Care
Patients with ADHD can be managed in a primary care setting . According to DSM-5, the diagnostic tasks are to ensure:
- Current symptoms present sufficiently (see Table 1.1).
- Age of onset of these symptoms is by age 12.
- Impairment in two or more roles due to these symptoms has been present for the last six months or more.
- A lack of alternate explanation for the symptoms or impairment, including a broad range of alternate medical (including mental health) and circumstantial conditions.
However, the following situations may require further consultation:
- Medical (physical) or psychiatric comorbidities are present and contributing significant morbidity or diagnostic uncertainty (refer to chapter 2).
- Failure to respond to recommended treatment algorithms (refer to chapter 5).
- Patient/family reluctance to accept diagnosis and/or treatment.
Note: Overall psychiatric health should always be considered and a risk assessment done at the onset.
There are several tools available to assist in the diagnosis of mental health problems. Examples of these general screeners are the Weiss Symptom Record (WSR) , the Patient Health Questionnaire (PHQ-9)  and the Generalized Anxiety Disorder Item-7 (GAD-7)  as well as the Screen for Child Anxiety Related Disorders (SCARED)  and the Kutcher Adolescent Depression Scale (KADS) . As always, therapeutic decisions should be based on a thorough evaluation of the patient with the most prominent or critical issues addressed first. This chapter provides information on how to systematically assess patients with ADHDconsistent features. Often fails to give close attention to details or makes careless mistakes in school work
Often fidgets with hands or feet or squirms in seat 2.
Often has difficulty sustaining attention in tasks or play activities Often leaves seat in classroom when remaining seated is expected 3.
Often does not seem to listen when spoken to directly Often runs about or climbs excessively in situations where it is inappropriate 4.
Often does not follow through on instructions and fails to finish school work
Often has difficulty playing or engaging in leisure activities quietly
Often has difficulty organizing tasks and activities Often is "on the go" or often acts as if "driven by a motor" 6.
Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort Often talks excessively 7.
Often loses things necessary for activities (e.g. school assignments, pencils, or books)
Often blurts out answers to questions before the questions have been completed 8.
Often is distracted by extraneous stimuli Often has difficulty awaiting turn 9.
Often is forgetful in daily activities Often interrupts or intrudes on others (e.g. butts into conversations/games)
Reproduced with permission from American Psychiatric Association Publishing Other Specified ADHD / Unspecified ADHD: Symptoms causing impairment but full criteria for ADHD are not met. *Total number of symptoms are less in adults (17+): 5 of 9 instead of 6 of 9
Chapter One of the Canadian ADHD Practice Guidelines and the CADDRA ADHD Assessment Toolkit have been designed to give frontline workers a convenient yet comprehensive step-by-step approach to the assessment and diagnosis of ADHD throughout the lifespan. The forms, assessment tools, and handouts referred to in the diagnostic algorithms are free to download from www.caddra.ca and to print and duplicate for your personal or practice use.
Rating scales and questionnaires can be used as an efficient way to obtain information from the patient and collateral sources, but are not sufficient for a diagnosis as other conditions may screen positive on ADHD rating scales (e.g. overlapping symptoms of depression or anxiety, or the presence of medical conditions like sleep apnea or anemia). A careful and thorough assessment reduces the risk of a false diagnosis of ADHD . These instruments, however, are effective screening tools and can be employed to document change over time and track treatment effects.

# Update on strategies for the diagnosis of ADHD
Establishing a diagnosis is an essential step in identifying pathology and developing a personalized treatment plan. Thus, clinicians are interested in keeping abreast of advances in diagnostic strategies. To address this need, a literature review spanning the past 10 years (2006-2016) on the diagnosis of ADHD was conducted. Only reviews, meta-analyses and randomized controlled trials were selected.
At this time, there is no evidence that any strategies beyond those described in the CADDRA Guidelines and recommended in the toolkit (namely the clinical interview in combination with rating scales), offer substantial benefit in the diagnosis of ADHD. The clinical interview and evaluation continues to be the mainstay of ADHD diagnosis.
Although rating scales alone are not sufficient to diagnose ADHD because of issues such as the variability of interpretation of questions by respondent, their use to enrich the process of evaluation is widely recommended .
Direct behavioural observation (i.e. observing the child in the classroom) is recommended by most sources , and has been complemented by standardized coding systems. However, it is associated with a high cost and may be possible where health professionals are also school personnel , but is generally limited to research settings.
While, neuropsychological and psychoeducational evaluations are frequently recommended, these are most useful in situations of diagnostic uncertainty  and should be interpreted in the context of a broader clinical evaluation given issues of sensitivity and specificity. Certain neuropsychological tests (Wide Range Assessment of Memory and Learning, California Verbal Learning Test, Wisconsin Card Sorting Test) have been recommended as particularly appropriate measures of ADHD . However, neuropsychological tests of executive function have low ecological validity. Not all individuals with ADHD, although functionally impaired by their ADHD, show impairment levels in standardized test data alone .
Furthermore, testing results should not be required to demonstrate below "average" functioning for a disability to be recognized and for the student to qualify for services and accommodations. Neuropsychological or psychoeducational testing should not be used to determine the severity of ADHD or quantify the impact of ADHD on cognitive or academic functioning as they do not accurately measure the nature of "real world" cognitive or academic impairments that characterize ADHD.
Computerized cognitive assessments (e.g. Conners' Continuous Performance Test, Test of Variables of Attention, Gordon Diagnostic System) have also been developed that specifically assess attention and response inhibition  but are associated with a degree of overlap between individuals with ADHD and controls .
Neuroimaging has identified structural alterations and dysfunctions in ADHD using population and research studies, but has no direct clinical application at this time .
Electroencephalography has been the focus of many publications . Children with ADHD may have an increase in absolute and relative theta and decreases in absolute and relative alpha and beta . This continues to distinguish adolescents and adults with ADHD . Having said this, EEG testing Is not a validated diagnostic tool for ADHD and CADDRA does not endorse its use for this purpose.
Red Flags for ADHD  
Organizational skill problems (time management difficulties, missed appointments, frequent late and unfinished projects).
- Erratic work/academic performance.
- Anger control problems.
- Family/marital problems.
- Difficulty in maintaining organized household routines, sleeping patterns and other self-regulating activities.
- Difficulty managing finances.
- Addictions such as substance use, compulsive shopping, sexual addiction, overeating, compulsive exercise, video gaming or gambling.
- Frequent accidents either through recklessness or inattention.
- Problems with driving (speeding tickets, serious accidents, license revoked).
- Having a direct relative who has ADHD.
- Having to reduce course load, or having difficulty completing assignments in school.
- Low self-esteem or chronic under-achievement.

# STEP 1: INITIAL INFORMATION GATHERING

# Reasons for Assessment or Referral
Individuals may come to you, or are referred, for a wide variety of reasons:
- Someone close to the individual (e.g., a relative, teacher, employer, colleague or friend) has learned about ADHD and recognizes these traits in the person.
The individual (typically an adolescent or an adult) has learned about ADHD and recognizes the relevant symptoms.
- A relative has already been diagnosed with ADHD and this diagnosis triggers an awareness of ADHD within the individual (e.g., a child is diagnosed and one or both parents think they may also have ADHD).
- There are functional difficulties that the individual presents with (such as behavioural or attention problems, academic issues, difficulty with paperwork, time management, driving, smoking or marital problems) and the clinician postulates ADHD as a possible explanation.
- Symptoms are attributed to another psychiatric diagnosis (mania, depression, anxiety, substance use disorder) but in fact could be related to ADHD. Some clinicians may be wary of an individual self-referring with a possible ADHD diagnosis. They may suspect that the person is looking for drugs, accommodations or an explanation/excuse for other problems. Clinical experience indicates this is an infrequent occurrence.

# Practice Point
- Review the individual's strengths and NOT just their areas of relative weakness.
- Establish a rapport with the individual and their family that makes future contacts easier and can aid intervention planning.
- Ensure that each interview ends with a statement about the coping skills that the individual and/or family have successfully used to work with difficult circumstances.
- Outline and affirm the importance and value of the individual and their family's efforts to succeed.
- Remember that self-referral neither guarantees nor eliminates a diagnosis of ADHD.

# Presenting Complaint and Documentation Initiation
Review with the individual and their family any concerns, the reason(s) for referral and the individual's/family's hopes for the assessment. Psychometric evaluations included in the CADDRA toolkit are designed to track the person's progress and assist with efficient and structured clinician charting. The diagnosis of ADHD cannot be done through the CADDRA toolkit alone but in conjunction with a diagnostic interview and attention to medical history, psychosocial elements and clinical presentation.

# SUGGESTED ACTION -AT THE END OF STEP 1
- Give the individual the relevant inventories necessary for the next visit (see appropriate 'Diagnosis and Treatment Flowchart' for the age group).
- Ask the individual and/or family to provide any relevant prior documentation (e.g., school report cards, previous assessments, etc.). Good school performance does not necessarily rule out ADHD. Individuals with ADHD may not accurately recall symptoms . Therefore, collateral information may assist in diagnosis.
The CADDRA Toolkit provides several forms (all available in the public domain), see flowcharts. An ADHD assessment should always include a general mental health screening (to consider comorbidities and differential diagnoses). In addition to a diagnostic interview, the CADDRA Toolkit contains optional assessment tools such as the CADDRA ADHD Assessment Form and the Weiss Symptom Record II (WSR II). The step-by-step flowcharts in this chapter apply after general mental health screening has been completed and ADHD is suspected. All the tools documented in this flowchart are free to download and use. Other assessment tools can be used in place of those proposed below.

# Practice Point
Communicating with the child or adolescent's school is crucial to collect information and implement appropriate measures. If parent(s) object to involving the school, the physician should let the parent(s) know that that an understanding of any ADHD-related difficulties in the classroom is needed to make a full assessment. In adults, collateral information provided by observer reports, such as from family members or partners, are important assessment tools.
Inconsistent reports (i.e. disagreement between parents, teachers, and partners) may require further exploration to better understand any discrepancy and may require referral.

# STEP 2: MEDICAL REVIEW
Objectives:
- Collect the documentation from past records when available.
- Score and review completed forms from Step 1.
- Complete the physical examination (or document that a physical examination was completed by a colleague) and review medical history to ensure that there are no other medical causes that could mimic or modulate ADHD symptoms.
- Discuss the possible complications / outcomes of having ADHD (e.g. accidents, poor sleep, nutrition, and substance abuse).
Ensure that there are no medical contraindications to the use of medications for treating ADHD (see chapter 5).

# SUGGESTED ACTION -AT THE END OF STEP 2
- Order any relevant clinical tests based on the physical findings to rule out medical causes and risk factors.

# STEP 3: ADHD-SPECIFIC INTERVIEW

# Objectives:
A complete childhood developmental history is an important part of a comprehensive assessment. Because accurate recollection of childhood symptoms and developmental history is difficult to obtain in adults, it is suggested to obtain, when possible, the point of view of a parent or a close family member who knows the individual's early history. The CADDRA ADHD Assessment Form offers an optional ADHD interview format and is available in the CADDRA eToolkit. The Diva 2.0 Diagnostic Interview for ADHD in Adults is another tool that can be downloaded at www.divacenter.eu in various languages .
In order to do a complete review, explore:
- Perinatal history (birth weight, complications, maternal alcohol and tobacco usage during pregnancy).
- Developmental milestones.
- Medical history (i.e. illnesses, concussions, seizures etc.)
- Impact of symptoms on learning, socialization and independent functioning.
Temperament.
- Symptoms of ADHD prior to the age of 12.
- Presence of any life events that were of emotional concern in childhood (e.g., abuse, bullying, divorce, loss, deaths, attachment issues).
- Content review of the completed forms with the individual and their family.

# Practice Point
- Review the person's strengths uncovered in the previous steps.
- Do not rely on ADHD symptoms observed during the interview as obvious symptoms of motor hyperactivity, impulsivity and inattention may not present in a one-to-one or novel situation. If observed during the clinical interview, this often suggests that the symptoms are more severe.
- Remember that a diagnosis of ADHD is made on symptoms and impairments reported rather than only on direct physician observation.
- Question not only the nature of the impairment and symptoms but the triggers that allow them to become apparent.
- Separate out symptoms caused by psychosocial stressors. This can be very difficult, particularly when the patient has suffered significant loss or trauma. It's important to differentiate any acute onset symptoms that may have been caused by recent stressors, such as loss or trauma, from the more chronic neurobiological symptoms of ADHD.

# SUGGESTED ACTION -AT THE END OF STEP 3
- Order any tests if necessary. If indicated, make referrals for further specialty assessments such as psychology, occupational therapy, speech language pathology, psychiatry or other medical specialists.
- Request a psychoeducational assessment if a learning disability or other cognitive challenges are suspected.
- Continue to emphasize the need to learn about ADHD and ensure that individuals and their families are aware of relevant websites for more information, such as: o CADDAC www.caddac.ca (Canada) o CHADD www.chadd.org (USA)

# STEP 4: FEEDBACK & TREATMENT RECOMMENDATIONS

# Feedback of the Diagnosis (if not previously done)
- Review all completed rating scales to determine if they meet criteria for ADHD.
- Review the developmental history, identifying impairments that are often associated with ADHD.
- For children/adolescents, review the CADDRA Teacher Assessment Form.
- Review all other available documentation, such as report cards and prior assessments.
- Give feedback related to the interview and collateral sources.
- Based on the findings above, present the diagnosis and any other concerns that might be relevant.

# Dispelling Myths
Many individuals and their families come into an assessment for ADHD with false information or beliefs. Some examples are:
- They are just lazy and looking for an excuse.
- I don't want my child to take medication that could change their personality.
- I am not the one with the problem, my spouse/employer/parent/teacher/school system is the problem.
- I had it as a child but it went away.
- I don't have all of the clinical symptoms.
- ADHD is just a fad.
- Plus, many more...

# Feedback of the Treatment Plan
- Address the feelings, questions and reactions to the ADHD diagnosis of the person with ADHD and their family.
- Explain the impact of the diagnosis in social/school/vocational settings. Documentation of the official diagnosis may be critical to receive various school interventions, benefits (e.g. special funding) and accommodations.
- Review the areas of impairment, trying to narrow down the primary symptoms that are troubling the patient.
Provide further education about ADHD (e.g. the CADDRA Information handout).
- Discuss psychosocial treatments (Chapter 4) and pharmacological treatment options (Chapter 5).

# Implementation of Treatment
- Treatment is often multimodal and should be individualized.
- Refer to chapters 4 and 5 for specific treatment guidelines.

# Follow-up
Regular and frequent follow-up is important until ADHD is stabilized. Once stabilized, active individualized monitoring based on a chronic disease management model should occur. Frequency of follow-up is dependent on patient characteristics such as medical complications, compliance, response to treatment, social supports and lifestyle factors.
The CADDRA Clinician ADHD Baseline/Follow-up and CADDRA Patient ADHD Medication forms can help streamline these visits.

# Practice Point
Regular monitoring includes completion of a growth chart for children plus rating scales, collection of vital signs, and side effects profiles whatever the age of the patient. 

# PREVALENCE OF COMORBIDITIES
When making an ADHD diagnosis, it is very important to note that, in the majority of cases, ADHD does not exist in isolation . An evaluation for ADHD requires screening for possible comorbid disorders and consideration of biological, social, and psychological factors. Consideration of a second opinion or referral to an ADHD specialist should be made if the patient has a clinical history that is complex or if you are contemplating pharmacological treatment beyond those recommended in these Guidelines .
Most individuals with ADHD have co-occurring conditions that may complicate the clinical presentation. Often these comorbid disorders need to be dealt with concomitantly . In some circumstances, as described later in this chapter, one may need to prioritize which condition to treat first.

# From the Literature:
- 50-90% of children with ADHD have at least one comorbid condition .
- Approximately half of all children with ADHD have at least two comorbidities .
- 85% of adults with ADHD meet criteria for a comorbid condition .
The literature offers multiple potential explanations for the existence of comorbidities and/or overlapping symptoms between ADHD and other disorders .
The main explanations are :
- One disorder is a precursor to another;
- One disorder is a risk factor for the development of the other;
- The disorders share the same related risk factors; or - There is a common underlying symptomatic basis for one or more of the behaviours in common. Comorbidity can contribute to the failure to diagnose ADHD in adults and children . In addition, follow-up studies of children with ADHD and comorbidity show that these children have a poorer outcome than children with ADHD alone, as evidenced by significantly greater social, emotional and psychological difficulties . The most common comorbidities identified in the Multimodal Treatment Study of ADHD  and in other comorbidity studies  have been remarkably consistent (e.g. Oppositional Defiant Disorder, Learning Disorders, Anxiety Disorders, Substance Use Disorders).

# Disorder-based Differentiation
Differential diagnosis is the process of differentiating between two or more conditions that share similar signs or symptoms while comorbid disorders are disorders that occur together with ADHD (either causallyrelated or independent and occur concurrent with ADHD). A careful assessment of other possible diagnoses should be undertaken at the time of evaluation. As ADHD does not have a symptom that is pathognomonic for the condition, there can be numerous overlaps with other disorders.
A thorough history and full functional review accompanied by a physical examination may highlight underlying physical conditions. While most individuals with ADHD do not need laboratory investigations as part of their diagnostic assessment, in certain instances, a laboratory work up or specific tests are needed to eliminate a suspected pathology.
Some special medical investigations may be required, such as polysomnography , electroencephalogram , or brain imaging . Psychological testing may be required to address a suspected learning disability  or other cognitive challenges. The clinical evaluation of a child with ADHD includes an evaluation of potentially adverse psychosocial factors such as a disruptive family environment , child abuse or neglect  and attachment issues . These may complicate the presentation of ADHD. - Neurofibromatosis
Medications that may have psychomotor side effects:
- Medication with cognitive dulling side effect (e.g. mood stabilizers).
- Medication with psychomotor activation (e.g. decongestants, beta-agonists like asthma medication).

# Common Comorbidities
In this chapter, we will briefly describe key comorbidities that can present alongside ADHD and the auxiliary treatments that they require.

# ADHD, Comorbidity & Development
- ADHD in its different presentations (combined, inattentive or hyperactive-impulsive), and the most common comorbid disorders, change over time and by developmental stage .
The most common comorbid disorders in early childhood are oppositional defiant disorder (ODD) , language disorders , and anxiety disorders .
- Many children with ADHD have a Specific Learning Disorder .
- ADHD may be two to three times more common in children with developmental disabilities or borderline IQ and intellectual disabilities .
In the mid-school-age years, symptoms of anxiety or tic disorders become more common .
- Mood disorders and substance use disorders tend to be more observable by early adolescence compared to childhood .
- In adulthood, anxiety, major mood disorders (depression or bipolar disorder)  and substance use disorders are commonly seen with ADHD .

# OPPOSITIONAL DEFIANT DISORDER
Behavioural problems (including oppositionality, aggression and delinquency) are among the most common comorbid presentations in children with ADHD . The presence of comorbid Oppositional Defiant Disorder (ODD) with ADHD is likely to generate substantial impairment and is expected to result in increased referrals for treatment . ODD rarely presents as an isolated diagnosis. Distinguishing between normal adolescent self-assertion and ODD may not always be easy. The impulsivity and irritability associated with ADHD is sometimes mistaken for the willfulness of ODD. In some individuals, ODD may continue into adulthood .

# Symptoms
DSM-5 symptom classification of ODD helps distinguish between the reactive-irritable symptoms that overlap with ADHD manifestations and the provocative-vindictive symptoms . The provocative-vindictive symptoms are less common and are often conceptualized as a reaction to insecurity or low self-esteem and may reflect reaction to a dysfunctional environment. The anxiety/depressive symptoms are associated with the irritable symptom construct of the DSM-5 .
DSM-5 provides three symptom clusters (mood related, provocative or vindictive) of ODD. It is useful to examine each symptom in light of its overlapping characteristics with ADHD. 

# Treatment
Treatment of comorbid ODD with ADHD should be multimodal . In patients with comorbid ODD with ADHD, it is advisable that the first step is optimization of pharmacotherapy of ADHD, which may stabilize the reactive-irritable symptoms . This should be followed by augmentation with psychosocial treatment, including Parent Management Training (PMT), Cognitive-Behavioral Therapy (CBT) or Collaborative and Proactive Solutions (CPS) . It is important to distinguish ODD from conduct disorder (CD). Children with ODD have recurring negativistic, defiant, hostile and disobedient behaviour, especially toward authority figures, whereas those with CD repeatedly violate the basic rights of others or ageappropriate societal norms, as defined by a pattern of repeated aggression, lying, stealing, and truancy . The onset of both disorders can be prepubertal, thus making early identification, diagnosis, and treatment crucial. In one study, ODD was found to be a precursor to conduct disorder in approximately 50% of the cases .

# Key Points
- Some patients with ADHD and ODD may respond adequately to stimulant or non-stimulant (atomoxetine, guanfacine XR) medications . Since many cases are likely to require augmentation with either psychosocial treatment and/or off-label use of another medication (for example; atypical antipsychotics) , referral to specialized care may be required in complex cases.
- Effective treatment may reduce the risk of more severe conditions in adolescent and adult years, such as CD, substance use disorder and depression .

# CONDUCT DISORDER/AGGRESSION
Conduct Disorder (CD) comorbid with ADHD is a severe, persistent condition that is frequently preceded by ODD . When CD has pre-pubertal onset (before the age of 10 years old), the prognosis is considered worse than for the group of children that have adolescent-limited CD . DSM-5 also emphasizes that limited pro-social emotions (lack of remorse or guilt; callousness and lack of empathy); being unconcerned about performance; and shallow or deficient affect are poor prognostic indicators and increase the risk for the development of antisocial personality disorders in adulthood . Furthermore, co-occurrence of ADHD and CD is often a precursor of nicotine use disorder, substance use disorder, anxiety, and depression .
Research shows that ADHD and CD represent two complex and distinct entities that can be associated . Children with either of these conditions in isolation present with different core symptoms and perform differently on objective measures of ADHD symptoms than those with ADHD + CD . Children with ADHD + CD show the poorest outcome within each individual group .

# Symptoms
The following table serves to help clinicians identify behavioural symptoms that may be seen in ADHD and may respond to specific treatments for ADHD. CD specific symptoms may require a multi-systemic approach and may also need to involve the legal system. 

# Treatment
Pharmacotherapy for patients with a combination of ADHD, CD and aggression using both stimulant and non-stimulant medications has been found to be useful . Although medications are usually effective in reducing the symptoms of ADHD and impulsive aggression , these patients typically receive more benefit from multimodal treatment .
Medications should initially be used to treat the most severe underlying disorder, but in some complex situations targeting specific symptoms could be appropriate. For example, patients with CD may show aggression before and during the course of treatment, making it imperative to document their aggressive behaviours before the introduction of medication and to make these behaviours an explicit target of therapeutic strategies. Clinicians should assess pharmacological treatment tolerability as some medications may augment irritability and aggression .
Conduct problems may be reduced by the most widely used evidence-based treatments for ADHD (e.g. stimulant and nonstimulant medication and psychosocial treatment) . However, treatment of the ADHD may not be sufficient to resolve all symptoms. Optimization of medication as part of a multimodal treatment approach indicated that psychosocial treatments including individual and family interventions are often required . Specialists in this area might use mood stabilizers or an atypical anti-psychotic (both are off-label). Other treatments (besides optimizing ADHD medication and psychosocial treatments) are controversial and referral to a specialist is recommended .

# Key Points
The essential characteristic of CD is repetitive and persistent behavior manifested by violation of others' fundamental rights or violation of social rules/norms.
- Psychosocial treatment, such as parenting and problem-solving skills training, and family and/or individual therapy, is often needed to improve patient outcomes.
- Pharmacological treatment of comorbid ADHD and CD may require combination of an ADHD medication and a medication that targets aggression.
- CD with ADHD represents a complex diagnostic entity that may require specialized interventions.

# ANTISOCIAL PERSONALITY DISORDER
Antisocial Personality Disorder (ASPD) is diagnosed when a pattern of antisocial behaviour has occurred since age 15. CD is, therefore, a precursor to ASPD. Many people with ASPD have a history of ADHD but most people with ADHD do not develop ASPD .

# Symptoms
Many of the ASPD symptoms have an impulsive component. It is therefore clinically indicated to carefully assess for ADHD in patients with ASPD. However, targeting and treating ADHD symptoms may not resolve ASPD symptoms as they are crystalized in the personality but may facilitate a structured intervention for the ASPD. 

# Treatment
Both disorders must be treated separately using the efficacious treatments for each specific condition. Since some patients with ASPD may exhibit drug seeking behavior (for secondary gain) or concurrent substance use disorders , clinicians may be sometimes reluctant to consider psychostimulant treatments for these patients, even if the ADHD is significant. Non-stimulant medications have not been systematically investigated in these patients but offer a treatment option for some underlying ADHD-related symptoms.

# Key Points
- ADHD is a treatable risk factor for ASPD.
- Both conditions require specific interventions and education may help to improve impulsive behaviours but ASPD traits need to be addressed separately.
- ASPD with ADHD represents a complex diagnostic entity and may require specialized interventions.

# BORDERLINE PERSONALITY DISORDER
According to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) , the lifetime prevalence of Borderline Personality Disorder (BPD) was reported to be 33.69% in those with ADHD versus 5.17% in the general population, suggesting an association between the two disorders. The most common symptom between ADHD and BPD is impulsivity .

# Symptoms
BPD and ADHD have shared and overlapping symptoms. The following table assists the clinician in distinguishing symptoms that are more specific to BPD from those that may overlap with ADHD. 

# Treatment
There are no studies establishing the optimal treatment for individuals with ADHD and BPD. The available literature suggests treating the two entities as separate phenomena . In addition, there is no current evidence to propose that an improvement in ADHD leads to a resolution of BPD, signifying that the personality features require specific treatments . However, most treatment strategies for BPD aim to control impulsive behaviours (often with medication), emotion dysregulation and distress tolerance . Currently, Dialectical Behavioral Therapy (DBT) is the most commonly recognized treatment for BPD . While all patients with core impulsivity are at risk of medication misuse, physicians must use their judgment and not necessarily deny patients with BPD effective treatments for ADHD.

# Key Points
- BPD with ADHD represents a complex diagnostic entity that requires specific mode of interventions.
- Psychosocial interventions like DBT have been shown to be effective for BPD and should be used in combination with psychopharmacology in the presence of ADHD.
- Stabilizing impulsive behaviours and optimizing emotion regulation should be the main goals of the combined psychosocial and pharmacological interventions.
- BPD with ADHD represents a complex diagnostic entity and may require specialized interventions.

# ADDICTIONS
In some individuals with ADHD, the need for rapid feedback, the desire for immediate reward and the high adrenaline riskseeking behaviours may render them vulnerable to addictions. These addictions may be to shopping, sex, pornography, internet and gambling, in addition to possible substance use disorders . Management principles for addictions and ADHD should include a specific intervention for the addictive behaviour and a specific treatment for the ADHD, ideally concurrently .

# SUBSTANCE USE DISORDER
Compared to typically developing individuals, people with ADHD have a two-fold risk for substance abuse and dependence . The literature suggests that one-quarter of adults with substance use disorder (SUD)  and one-half of adolescents with SUD have ADHD . Several studies suggest a higher rate of SUD in adults with ADHD than in the general population, and ADHD itself is a risk factor for SUD . Among ADHD patients with a comorbid behavior disorder, those with either comorbid CD or Bipolar Disorder have the greatest likelihood of developing SUD .
Individuals with ADHD are at significant risk of using substances (e.g. nicotine, cocaine and cannabis) and of starting use earlier than the general population . Moreover, the accompanying poor self-esteem and impulsivity associated with ADHD may be conducive to the development of SUD.
Marijuana continues to be the most commonly abused agent in individuals with ADHD . Abuse can include alcoholism, smoking and other drugs . Furthermore, substance use problems may increase the severity of ADHD symptoms. On the other hand, it is also true that patients with these substance use problems may present with attention, behaviour and self-control symptoms that can mimic ADHD. A referral to a specialist may be required before establishing an ADHD diagnosis when a patient is actively using illicit substances.

# Treatment
The best approach to treatment sequencing in individuals with ADHD and comorbid substance use disorder is concurrent intervention with specific interventions for each disorder . Some researchers suggest that ADHD and SUD-related craving share neurobiological similarities, and that treatment of ADHD may reduce craving for substances and subsequently reduce the risk for relapse to substance use . An aggregate of the literature seems to suggest that early stimulant treatment reduces or delays the onset of SUDs and perhaps cigarette smoking into adolescence; however, the protective effect may be lost in adulthood .
The treatment needs of individuals with ADHD and SUD need to be considered simultaneously; however, if SUD is severe, sequential treatment may be considered with immediate attention paid to the stabilization of the addiction. Depending on the severity and duration of the SUD, individuals may require residential or inpatient treatment. Day treatment can be a more cost-effective option if patients are ready and motivated for change . Depending on the type of substance being used, prescribing psychostimulants in the presence of active substance abuse requires careful monitoring for medical interactions and should take into account the potential risk of misuse and abuse .
Although patients commonly report subjective calming with cannabis and other improved symptoms (increased appetite, better sleep), there is no evidence that cannabis is an effective treatment for ADHD or that it improves attention and productivity. In fact, there is evidence that cannabis can impair cognition and exacerbate motivation issues .
Methylphenidate does not have the same abuse liability as cocaine due to slower dissociation from the site of action, slower uptake into the striatum, and slower binding and dissociation with the dopamine transporter protein relative to cocaine . However, it is important to remember that the route of administration may alter the abuse liability of a substance. The oral administration of psychostimulants has been shown to decrease the likability of a substance while parenteral usage (injected, snorted) has been shown to be associated with euphoria . Individuals with ADHD and either SUD or CD are at highest risk for diversion and misuse and are more likely to both misuse and divert their stimulant medication . Both immediate-release and, to a lesser degree, extended-release preparations of stimulant medications can be diverted or misused, with extended release preparations having less potential for parenteral usage . Nonstimulants such as atomoxetine and guanfacine XR do not have abuse potential.

# Key Points
- In most cases, ADHD and SUD need to be treated concurrently and independently when comorbid.
- Psychostimulants taken orally do not have the same abuse liability as illicit stimulants (e.g. cocaine) due to slower dissociation from the site of action, slower uptake into the striatum, and slower binding and dissociation with the dopamine transporter protein.
- Non-stimulant and long-acting psychostimulants have less abuse potential than immediate-release preparations of psychostimulants.

# ANXIETY DISORDER
As many as a third of children and half of adults with ADHD have comorbid anxiety . Individuals with ADHD often develop symptoms of anxiety due to chronic difficulties related to their ADHD symptoms. For instance, the experience of repeatedly forgetting may lead to realistic worries that one will forget. Compensatory checking may mistakenly be interpreted as evidence of a primary anxiety disorder.

# Symptoms
The table of specific versus commonly seen symptoms may help clinicians distinguish ADHD from anxiety disorders. 

# Treatment
If ADHD exists with anxiety, a general rule of thumb is to treat the most impairing condition first . Psychostimulant treatment may increase anxiety especially during treatment initiation, or when increasing dosages of medication . A slower than usual titration schedule may be preferred in these cases. If the anxiety becomes too intense, then the ADHD medication should be reduced or withdrawn, and the anxiety should be treated until the symptoms are stabilized and only then should the ADHD medications be started. Any of the ADHD stimulants can be successfully used when anxiety is comorbid with ADHD . A randomized-controlled pediatric study showed that the non-stimulant atomoxetine can be beneficial in patients with co-occurring ADHD and anxiety disorders . Guanfacine XR was found to be well tolerated in pediatric subjects with anxiety disorder .

# Key Points
- ADHD-associated impairments can induce anxiety symptoms that are different from a specific anxiety disorder.
- Anxiety disorders and ADHD often coexist, and the most impairing condition should be treated first.
Stimulants and non-stimulants can be used for ADHD in the context of anxiety.
- Titration of psychostimulants may need to be initiated at a slower pace and monitored more carefully with patients prone to anxiety.

# MAJOR DEPRESSIVE DISORDER
There is considerable overlap between the clinical presentations of Major Depressive Disorder (MDD) and ADHD. MDD patients (without ADHD) may have depressive episodes presenting with inattention, short-term memory problems, irritability, impulsivity, difficulty sleeping, trouble concentrating, restlessness and fidgetiness . A critical point to explore is the "since when" question, as a reported recent drop in mood is qualitatively different from the lifelong demoralization that may be seen in ADHD .

# Symptoms
Patients with primary ADHD often have to deal with failure and attacks to their self-esteem, frequently at a very young age, and may become demoralized and depressed as a result. In this case, they may present with both disorders. However, patients with ADHD may look like they have a mood disorder when they do not. Lack of motivation may mimic anhedonia and chronic difficulty going to sleep and restless sleep may mimic insomnia secondary to MDD. Patients with ADHD commonly have dysregulated mood (dysphoria, irritability), but it is not typical for ADHD in the absence of a mood disorder to be associated with entrenched, depressed affect or anhedonia. 

# Treatment
When a patient with ADHD also suffers from MDD, treatment of the most disabling condition should be undertaken first. It is important to note that if the depressive episode is part of a Bipolar Disorder, the treatment algorithm should follow that of Bipolar Disorder (see section on Bipolar Disorder). In some patients, antidepressants with catecholaminergic activity, such as bupropion, can be useful to treat both MDD and ADHD. Typically, the combination of an antidepressant (e.g SSRIs) with psychostimulants may be necessary to achieve remission. SSRIs are considered safe to use in combination with stimulants. However, drug interactions involving the CYP450/2D6 (e.g., involving fluoxetine, paroxetine), when combined with the amphetamine class or atomoxetine, require caution and monitoring.
If the MDD continues to be impairing or worsens, referral or specialized care in depression is recommended. In severe depression, and in subjects at risk of self-harm, intervention for depression and specialized referral must be carried out as a priority.

# Key Points
- If a patient presents with mild depression and ADHD, then treatment of ADHD may be considered first.
In cases of depression or severe suicidal risk, treatment for depression must be the priority.
- Concurrent treatment of ADHD and major depression is often required, and concomitant use of antidepressants and ADHD medications are commonly used.

# BIPOLAR DISORDER
The diagnosis of Bipolar Disorder (BD) in the context of ADHD is challenging. Many symptoms of BD overlap with ADHD symptoms. The definitive epidemiological relationship between both disorders remains controversial. The following table may guide clinicians in differential diagnosis. However, if Bipolar Disorder is suspected, a referral to specialized care should be considered. 

# Symptoms

# Treatment
Treatment of comorbid ADHD and BD should usually start with managing and stabilizing the BD symptoms first .
The management of ADHD with BD is usually more complicated than managing ADHD alone and often requires the use of mood stabilizers and/or atypical antipsychotics . There is a small risk of switching from euthymia or depression to mania when a bipolar patient is prescribed stimulant medication . If this occurs, the stimulant should be adjusted (reduced) or discontinued, and treatment of BD should be prioritized. Once the patient's mood is stabilized, stimulant medication may cautiously be re-instituted (start low and go slow) .

# Key Points
The co-occurrence of BD and ADHD may be difficult to diagnose and manage. A referral to a specialist should be considered.
- Treatments should be aimed at stabilizing the Bipolar Disorder first and then treating ADHD.
- Stimulants have been shown to be safe and effective in patients with BP once their symptoms have been stabilized.

# DISRUPTIVE MOOD DYSREGULATION DISORDER
The diagnostic criteria for Disruptive Mood Dysregulation Disorder (DMDD) includes severe recurrent disproportional temper outbursts (verbal and/or physical) occurring three or more times a week in at least two different settings for 12 months or more . Diagnoses are generally made between the ages of 6 and 10 and cannot first be made before the age of six years or after the age of 18 years . Between temper outbursts, the mood of the patient with DMDD appears to be irritable/dysphoric .
DMDD is currently considered a presentation of childhood depression and this diagnosis was created to address concerns about the potential for the over diagnosis of, and treatment for, bipolar disorder in children . A study of some 3,258 participants aged 3 to 17  showed a prevalence rate for bipolar disorder of 0.8% to 3.3% with the highest rate in preschoolers. DMDD was also found to be very comorbid (62% to 92%). The highest rates of comorbidity occurred with depressive disorder (odds ratio 9.9 to 23.5) and ODD (52.9% to 100%). Rate of co-occurrence with ADHD had odds ratios which ranged from 2.9 to 12.

# Symptoms Table 2.9 Disruptive Mood Dysregulation Disorder (DMDD) Differentiation OVERLAPPING SYMPTOMS WITH ADHD DMDD DISTINCT FEATURES Irritable mood episodes (explosive outbursts)
Inter-episode dysphoria Psychomotor agitation
Minor triggers with extreme rage attacks Chronic course Young age of onset

# Treatment
A combination of medications and psychosocial interventions is needed to treat ADHD + DMDD. Many of the medications effective for treating ADHD have been shown to be effective for DMDD .

# Key Point
- DMDD is a new DSM-5 diagnosis. Research regarding its treatment and relationship to ADHD is underway.

# OBSESSIVE-COMPULSIVE DISORDER
The lifetime prevalence of Obsessive Compulsive Disorder (OCD) in the general population is 1-3% . Reported rates of ADHD-OCD co-occurrence are highly inconsistent in the literature . If OCD and ADHD present together, there is an increased risk of Tic Disorders and Tourette Syndrome also being present . ADHD patients often develop behavioural patterns, like repetitive checking of tasks, as coping strategies to compensate for the symptoms of ADHD. Whether these behaviours are secondary to ADHD or are indicative of OCD needs to be considered.

# Treatment
Treatment of OCD and ADHD should be carried out simultaneously. While there are no controlled studies, a 2014 review  reported no evidence showing a worsening of OCD symptoms with the concurrent use of psychostimulant medications.

# Key Points
- Psychostimulants do not usually lead to an exacerbation of OCD symptoms .
- The presence of OCD comorbidity does not change the treatment approach to either disorder.

# TOURETTE SYNDROME AND TIC DISORDERS
ADHD is highly comorbid with tics and Tourette Syndrome (TS) (50-90%) , so patients with tics should be screened for ADHD. In a 2014 study, four clusters of individuals were identified: pure TS (49.8%), TS + ADHD (22.2%), TS + OCD (21.5%) and TS + ADHD + OCD (6.5%) . A commonality to all groups was emotional lability. All groups had significant behavioral problems compared to normal controls. The presence of OCD is considered to be more impairing than the presence of ADHD and is more likely to increase the rate of other co-morbidities , though there are no current long-term studies on treatment outcome for these four groups. When tics co-occur with ADHD, the tics themselves are generally less impairing than ADHD .

# Treatment
Recent research studies suggest that treatment interventions for TS include education about tics and related disorders, clinical monitoring, pharmacological and/or psychological treatments, and school interventions for children and adolescents . Stimulant medication is a safe and effective treatment for ADHD + Tic Disorder but requires careful monitoring of potential tic worsening ; the alpha-2-adrenergic agonists, clonidine and guanfacine XR, have shown promise in the treatment of tics, particularly in combination with ADHD . In patients where stimulants may cause tic exacerbation, atomoxetine may be also considered as an option as it will rarely cause worsening of symptoms .
Recent studies indicate that on a population level stimulants do not seem to raise the risk of tics, and that the exacerbation of tics when stimulants are started is often coincidental, having to do with the waxing and waning nature of tics .
Non-pharmacological treatments for Tic Disorder include Habit Reversal Therapy and Comprehensive Behaviour Intervention for Tics (CBIT)  and may be considered as first-line treatments when available.

# Key Points
- Tics and TS are highly comorbid with ADHD.
The presence of tics or TS is not a contraindication to the use of stimulants in ADHD but careful monitoring is required.
- Stimulants do not typically raise the risk of tics but may rarely do so in some individuals.

# EATING DISORDERS
Bulimia nervosa is more prevalent in patients with ADHD versus patients without ADHD . ADHD is more prevalent in anorexia nervosa purging type . Females with ADHD are 3.6 times more likely to meet the diagnosis of eating disorders compared to females without ADHD . The prevalence rate of ADHD in eating disorders is 11.4% . This would suggest that females with ADHD in particular should be screened for an eating disorder, and vice versa. Clinicians should be alert as patients with anorexia that may not have ADHD may seek stimulant medication (feigning symptoms of ADHD) for the purpose of weight loss. Obesity has also been reported among patients with ADHD, especially in the adult population .
One of the proposed mechanisms underlying weight issues in patients with ADHD could be the impulsive behaviours leading to binge eating . Impulsivity is greater in individuals with comorbid eating disorders than in individuals with ADHD alone . It is important to recognize that obesity is a risk factor for sleep apnea , a condition that may mimic or aggravate ADHD symptoms. Therefore, the longitudinal course of symptoms is of crucial importance before making a diagnosis of ADHD in obese patients with sleep apnea. . Binge Eating Disorder is a newly recognized disorder in DSM-5 and its relationship with ADHD is currently unclear.

# Key Points
- The diagnosis and treatment of ADHD in the presence of anorexia nervosa can be complicated.
- Treatment of ADHD could contribute to behavioral control in the context of binge eating.
- A growing body of literature points to ADHD as a risk for obesity.

# AUTISM SPECTRUM DISORDER
Until the publication of the DSM-5, Autism Spectrum Disorder (ASD) was an exclusionary criterion in making the diagnosis of ADHD, and the two diagnoses could not be made concurrently. Because of this, the relationship of ADHD and ASD remains unclear and is currently being researched. Prior research has suggested as many as 30 to 70% of patients with ASD may meet criteria for ADHD . Many individuals with ADHD also show high level of social deficits and ASD type symptoms . 

# Symptoms

# Treatment
Treatment of ADHD in patients with ASD is effective and significantly improves functioning. There have been only a small number of Randomized Controlled Trials (RCTs) that have looked at treatment of ADHD symptoms in subjects with comorbid ASD but these have shown promising results .
RCTs with methylphenidate in comorbid samples have shown a response rate of 50% (versus 70-80% response rate for psychostimulants in ADHD without comorbid ASD) . Additionally, patients with ADHD and ASD may be more sensitive to side effects such as irritability, hyper focus, and stereotypies than those without ASD . Clinical experience indicates that medications should be started at low doses and titrated more cautiously than usual in this population .
Both risperidone and aripiprazole (off-label use) have shown efficacy in controlling hyperactivity in this population, but generally have a less favorable side effect profile (metabolic changes, weight gain) than psychostimulants .
One RCT of atomoxetine in individuals with ADHD and ASD showed positive results in improving hyperactivity, impulsivity and inattention and was generally well tolerated; however, overall improvement in clinical and functional improvement was limited . Extended release guanfacine has recently been found to be effective for reducing hyperactivity in children with ASD .

# Key Points
- ADHD patients should be screened for ASD and vice-versa.
- Treatment of ADHD in patients with ASD can be very effective and help overall functioning.
- Treatment of comorbid ADHD and ASD with standard ADHD medication is often effective but may have lower effect sizes and higher risks of side effects.

# SPECIFIC LEARNING DISORDER

# Symptoms
Children/adolescents with ADHD frequently fall below their typically developing peers in their scores on standardized achievement tests. Teachers and parents often express concerns about a child's level of productivity and may label this child/adolescent as "lazy" or "unmotivated". There are several trajectories that can culminate in underachievement. One of the possibilities is that the individual has both ADHD and a Specific Learning Disorder (SLD). Indeed, research indicates that the comorbidity of ADHD and SLD is as high as 45% . It is important to note that the comorbidity range suggested to be between 31% and 45% can vary greatly depending on how SLD is diagnosed .
Even without comorbid SLD, people with ADHD may still have a great deal of difficulty academically in terms of listening and reading comprehension and written expression (as well as with performance deficits such as following instructions, listening in the classroom, or staying on task) . Additionally, individuals with ADHD often have executive function difficulties in the areas of initiation, organization, planning, self-directed activity, and ability to complete multistep tasks .The degree of difficulty individuals experience varies, with some individuals greatly impaired and their academic achievement subsequently falling well below their abilities. Learning disorders and executive function deficits are also developmental. That is, they may become more overt as cognitive demands in school increase . Note: SLD is a clinical diagnosis that is not necessarily synonymous with 'learning disabilities' as identified within the education system: that is, not all children with learning disabilities/difficulties identified by the school system would meet a DSM-5 clinical diagnosis of SLD. By contrast, those with a DSM-5 diagnosis of SLD would be expected to meet the educational definition .

# Diagnostic Assessment
In terms of assessment, practitioners should always: a) Screen for academic skills deficits among students with ADHD and for ADHD symptoms among students with SLD. b) Assess academic functioning across subject areas (e.g., reading, math, writing) when evaluating students with ADHD. c) Carefully evaluate whether interventions for ADHD enhance academic functioning.
Given the relatively high comorbidity rate between ADHD and SLD, students who are evaluated for one of these disorders should always be screened for possible symptoms of the other disorder. The CADDRA Teacher Assessment Forms screens for academic performance problems in addition to ADHD. If the screening suggests the possibility of an SLD, then a letter should be sent to the school, with the parent's approval, to notify them and suggest that the school may wish to consult with support staff and/or the board psychology practitioners for further investigation and school programming.
In adults, as in children, ADHD can occur along with specific problems in reading, math or with written expression .
Assessing whether these difficulties have caused previous problems in school and continue to cause residual difficulty can usually identify these. The childhood history should reveal previous concerns of ADHD. It is additionally important to determine if the patient is inattentive only in the area in which learning deficits present a challenge.

# Management
Learning disabilities require intensive, direct instruction, and modifications/accommodations . Comprehensive intervention services for students with comorbid ADHD and SLD will require empirically supported treatment strategies that address both disorders and that are implemented across school and home settings. Although some school boards across Canada do not currently recognize ADHD as qualifying a student as a 'special needs student', this perspective is changing. Clinicians wishing to advocate for accommodations for their ADHD patient may wish to use the CADDRA Educational Accommodation Template.

# SPECIAL PRESENTATIONS

# Intellectual Giftedness
Research has shown that having a high IQ does not preclude the possibility that one might have ADHD . However, the co-occurrence of ADHD and intellectual giftedness remains controversial and under-investigated. Most previous discussions in the literature have been based largely on anecdotal comments, opinions and small clinical samples. Moreover, DSM-5 does not mention ADHD in the context of intellectual giftedness .
Misdiagnosis of ADHD in the context of intellectual giftedness can occur in two ways: intellectually gifted individuals with high energy and over-excitability in school contexts (particularly in those with little academic stimulation) may be misdiagnosed as having ADHD; alternatively, intellectually gifted individuals who meet full diagnostic criteria for ADHD but who can concentrate for long periods of time, may not be diagnosed with ADHD . Moreover, intellectually gifted individuals with ADHD may also meet criteria for SLD and other comorbidities . Thus, it is important for practitioners to recognize that intellectual giftedness in individuals with ADHD should be documented.
A high IQ may help individuals with ADHD cope with symptoms. Therefore, in some cases, clinically relevant impairment among gifted IQ children may not develop until later in elementary school or even in high school . However, although ADHD may not be diagnosed until later it is not any less impairing. Diagnosis and treatment is critical at any age.

# Symptoms
There are overlapping symptoms shared by individuals with high IQs and individuals with ADHD which may make differential diagnosis challenging. Frequently, bright children are referred to psychologists or pediatricians because they exhibit certain behaviors commonly associated with a diagnosis of ADHD (e.g., restlessness, inattention, impulsivity, high activity level, day-dreaming). A child may be diagnosed with ADHD when in fact the child is gifted and reacting to an inappropriate curriculum . The process of completing a differential diagnosis requires specific questions to clarify what is shared and what is unique to either ADHD or giftedness or whether the child is twice exceptional.
In general, intellectually gifted individuals with ADHD show a similar pattern of cognitive, social, psychiatric, and behavioral characteristics as those with ADHD in the context of average IQ . However, the individual's strengths and difficulties may interact so that one presentation obscures the other .
Practitioners will need to undertake a thorough medical, developmental and educational history, as well as a comprehensive clinical and psychological evaluation, to ascertain an individual's behavior in different contexts and situations. The National Commission on Twice Exceptional Students concludes that the 'identification of twice-exceptional learners requires comprehensive assessment in both the areas of giftedness and disabilities . When possible, the assessment and identification should be conducted by professionals from both disciplines (i.e., ADHD, giftedness) and ideally by those with knowledge and experience with individuals with twice-exceptionality.

# Psychological Trauma
The interaction between psychological trauma and ADHD can be complex. Post-trauma symptoms of hyperarousal, hypervigilance, and dissociation can confound ADHD assessment. Although there is conflicting evidence, a history of psychological trauma may increase the risk of being diagnosed with ADHD .
Various explanatory hypotheses are being explored in the literature to explain the interaction between trauma-related symptoms and ADHD symptoms . First, ADHD may place children at greater risk for exposure to psychological trauma . Conversely, Post Traumatic Stress Disorder (PTSD) symptoms may mimic symptoms of ADHD . Additionally, some initial animal research suggests the individual response to trauma (i.e. externalizing vs. internalizing) may be influenced by genetic predispositions . Under this latter hypothesis, trauma exposure merely exacerbates a prepotent genetic propensity towards having ADHD.
Although increased care should be taken to ensure the effects of historic trauma are considered during the assessment process, a history of trauma exposure does not automatically preclude the diagnosis of ADHD in an individual who otherwise meets DSM-5 criteria for ADHD. Further, in the absence of research evidence to the contrary, clinicians are encouraged to follow the normal ADHD treatment protocols described elsewhere in these guidelines.
Clinicians are advised to: a) screen for history of psychological trauma and where indicated, ensure appropriate trauma-informed support and interventions are mobilized; and b) assess for ADHD based on DSM criteria, and treat in accordance with these guidelines.

# Developmental Coordination Disorder
The prevalence rate of Developmental Coordination Disorder (DCD) in the general population is 1.7% in 7-to 8-year-olds . There is no reported prevalence of the co-occurrence of ADHD + DCD, in large part because DCD is often still unrecognized. Clinicians are urged to do simple assessments of balance as part of the routine workup of ADHD including: observations of gait, throwing and catching a ball, balancing on one foot (first identifying dominance) and fine motor tasks such as writing, use of scissors or drawing .
Balance problems, dyslexia, and poor handwriting in comorbid patients may be related to cerebellar dysfunction and may be associated with DCD . Occupational therapy assessment is warranted to provide recommendations .
Having the person learn keyboarding can often be beneficial. Relevant software programs (e.g. voice recognition) can also help to overcome problems.

# Epilepsy
Studies have suggested a higher incidence of symptoms of ADHD in children with epilepsy (20% to 50% of patients) than in the general population . There is a strong trend towards a higher incidence of epilepsy among children with ADHD than among children without ADHD  and epilepsy in children with ADHD appears to be more severe than in those without ADHD . Anti-epileptic medications side effects, which can impair attention and learning, may be confused with ADHD symptoms. Therefore, improving seizure control with anti-epileptic medications that have less potential for behavioural or cognitive side effects should be a priority. In those patients with a formal diagnosis of ADHD in the presence of epilepsy, a pharmacological intervention as part of a biopsychosocial approach to treatment could be considered. No strong evidence exists that psychostimulants increase the severity or frequency of seizures in patients with stable epilepsy .

# Key Points
- When choosing an anti-epileptic medication, one that has less potential for behavioural or cognitive side effects should be preferred in the context of comorbid ADHD.
- Use of psychostimulants could be appropriate in patients with epilepsy provided seizures are well controlled by antiepileptic medications.
- Consideration needs to be given to metabolic drug interaction between ADHD medications and anti-epileptics.

# Brain Injury
Individuals with ADHD of all ages are at risk for physical injuries because they are impulsive, hyperactive and/or inattentive. Children and teenagers with ADHD are three times more likely to experience a moderate or severe brain injury than their peers without ADHD . Any injury to the brain, particularly to the frontal lobes, can produce a syndrome known as Secondary ADHD (S-ADHD) , also referred to as acquired ADHD. Recent literature has shown that the brain correlates of S-ADHD include the lesions in right putamen, thalamus and orbital frontal gyrus .
Children and adolescents with a moderate or severe brain injury have between a 20 to 48% chance of developing S-ADHD . S-ADHD can be treated using the same principles and medication as ADHD, but the research literature supporting this treatment is not as extensive or compelling as it is for ADHD.
Given that concussion and brain injuries are relatively common, and symptoms of persistent impairment could mimic or exacerbate the symptoms of ADHD, it is recommended that all patients being assessed for ADHD should be questioned as to whether they have ever suffered a concussion or brain injury. The literature on the association between ADHD and nontraumatic acquired brain injuries such as fetal alcohol syndrome, stroke or treatment with neuro-toxic medications is less clear, but many of these types of patients who develop ADHD symptoms may respond to standard treatments . Patients with brain injury may be more sensitive to medication and thus starting off at lower doses during medication titration trials is recommended .

# Key Points
- Assessment for ADHD includes inquiring if the person has suffered a concussion or brain injury.
- Patients with S-ADHD due to traumatic brain injury can be treated with same approaches and medication as regular ADHD although lower starting doses may be considered.

# Sleep
Sleep problems, particularly the symptoms of insomnia (i.e., difficulties falling asleep and staying asleep, and early morning awakenings), are very commonly reported by individuals with ADHD. In fact, at least 50% of children and adults with ADHD report significant sleep problems . While there is a high rate of reported sleep problems in individuals with ADHD, there have been inconsistent findings when objective measures of sleep, such as actigraphy and polysomnography, have been used in research . Across studies examining sleep in children with ADHD, the main finding is that individuals with ADHD have more restless sleep than their peers, which can lead to fragmented sleep. There have been no consistent differences found in terms of sleep variables such as sleep duration  or sleep architecture (i.e., differences in the amount of REM sleep or NREM sleep) in individuals with ADHD . There is consistent evidence that stimulant medications used to treat ADHD symptoms could make falling asleep more difficult, which can potentially result in shorter night sleep . Shorter and/or fragmented sleep can result in problems with daytime functioning. There is also growing evidence for possible differences in circadian rhythms, which could make individuals with ADHD more vulnerable to delayed-phase sleep disorder and other types of sleep problems .
Research has clearly shown that insufficient sleep in children and adults can result in difficulties with attention, emotional and behavioural regulation, cognitive functioning (e.g., memory), and academic performance . It would be logical to assume that individuals with ADHD may be even more affected by insufficient sleep given their existing vulnerabilities in these areas. However, very little research has been conducted to determine if this is the case, but in the few existing studies, there is some evidence for this assumption. For example, in one study, sleep restriction negatively impacted both typically developing children and children with ADHD, but only the ADHD group moved into the clinical range on an attention task .
While there is a need for more research to better understand the relationship between sleep and ADHD , it is clear that we need to be attentive to sleep problems when conducting assessments and/or developing treatment plans for individuals with ADHD. First, we need to think of differentials in our diagnostic formulations. For example, sleep apnea can mimic or aggravate ADHD symptoms . Also, given that medications used to treat ADHD can impact sleep, it is important for sleep to be monitored when an individual is taking these medications. It is also likely that sleep problems could exacerbate ADHD symptoms, and therefore, sleep problems should be addressed in the treatment plan.

# Treatment
While there is little evidence for pharmacological treatment of sleep problems in individuals with ADHD , there is a growing body of literature that demonstrates that behavioural sleep interventions can be effective for children with ADHD, even when taking stimulant medication . Many individuals with ADHD take melatonin to help with their sleep problems, and the very small body of research has demonstrated that this may be an effective intervention . However, given that there is limited research, and the fact that behavioural interventions have been shown to be effective, it is recommended that the first line of treatment is behavioural interventions for sleep problems in individuals with ADHD. For a comprehensive overview of assessment and management of sleep problems in individuals with ADHD please see  or .

# Key Points
- Differential diagnosis needs to be considered in diagnostic formulations (e.g., sleep apnea can mimic ADHD symptoms). 

# Incontinence
ADHD and incontinence (nocturnal enuresis, daytime urinary incontinence, and fecal incontinence) are strongly associated with each other. Children with ADHD are two to three times more likely to have enuresis than those without ADHD . In typically developing samples, the rate of enuresis is 4.45% in boys and 2.5% in girls, with prevalence rates decreasing with age. The trend is similar for fecal incontinence  and daytime urinary incontinence . Likewise, children with nocturnal enuresis are more likely to have ADHD than those without incontinence .

# Treatment
In most cases, ADHD and issues of incontinence need to be investigated and managed separately. However, recent studies have found that successful treatment of ADHD with stimulant medication can result in resolution of incontinence in some children . Enuresis treatment must begin with the correction of any underlying medical cause. Daytime enuresis may be improved with medication. Nighttime enuresis often requires individualized management. In a double-blind study, atomoxetine has been associated with a significant increase in dry nights in children with nocturnal enuresis .

# CHAPTER 3: SPECIAL CONSIDERATIONS ACROSS THE LIFESPAN
ADHD is a persistent disorder, with functional impairment and treatment needs varying through the lifespan for many. It is important for clinicians to be aware of these differences to better serve individuals with ADHD. Below is a summary of the functional impairments commonly seen across different age groups for individuals with ADHD. 

# OVERVIEW Preschool children
Hyperactivity in preschoolers tends to be temporally and situationally stable  and is highly heritable . However, clinicians should remember that inattention and hyperactivity in preschoolers can be influenced by a number of factors. These can include intellectual impairment, expressive language issues, and their response to child abuse and neglect as well as conflictual environments .
Epidemiological data indicates that approximately 2-7.9% of children from three to five years of age have ADHD . The American Academy of Pediatrics has suggested that ADHD can be diagnosed in children as early as age four . Nonpharmacological approaches should be the first-line treatment for preschool children .

# School-aged children
ADHD is one of the most common psychiatric disorders diagnosed in children. Prevalence rates range from 3 to 9% of school-age children . A recent meta-analysis determined that the prevalence rate for children and adolescents was 7.25% .
Research indicates that girls may be consistently under-identified and under-diagnosed . Commonly seen differences between boys and girls with ADHD exist during this period :
- Boys may be three times more likely to be identified; girls are consistently under-identified and underdiagnosed.
- Girls with ADHD have lower levels of disruptive symptoms than boys with ADHD.
Childhood is usually the time where ADHD is diagnosed for most individuals. Challenges may occur in all areas of the child's life including at school, at home and during social activities. Interventions are aimed at minimizing the functional impairment that can occur and are part of what is known as a multimodal approach to treating ADHD.
There can be associated problems with ADHD, such as learning difficulties or low self-esteem, which must be managed in addition to the ADHD symptoms. The clinician must utilize the resources available in the team or in the community to provide additional supports for the child and the family. This may be through referral to other professionals such as a psychologist, occupational therapist, social worker, educational aid, resource teacher or behavioural consultant. Examples of useful accommodations for school-aged children can be found at www.caddac.ca under the 'Understanding ADHD In Education' tab.

# Adolescents
Prevalence rates of ADHD in the adolescent population range from 6-12% . Between 50% and 80% of youth diagnosed with ADHD in childhood maintain significant symptoms and meet diagnostic criteria for the disorder in adolescence . Males are three times more likely to be diagnosed with ADHD than females . This discrepancy starts to lessen over time nearing adulthood.
As children grow into adolescents, it is important to work with both the individual and their parents together. This acknowledges the emerging autonomy of the adolescent. Clinicians should not rely exclusively on the parent as an intermediary. It is important to use language that adolescents can understand and avoid the use of excessive medical jargon. Adolescents should at some point be seen alone and during that time the clinician should develop rapport directly with the adolescent and obtain a history of risk factors such as reckless driving, smoking, drug use, sexual activity, family or interpersonal conflicts, illegal activities and issues of bullying. A review of their peer relationships helps to assess their social development and to flag any risky behaviour. Peers tend to be in trouble together.
Adolescents with ADHD are not always the best historians. They frequently do not have full insight into their condition and they may have a self-centered perception and a tendency to deflect blame onto others . Gathering collateral information from key people who know the adolescent can be very helpful. Even though there can be considerable variability in ratings completed by adolescents, serial ratings (see CADDRA ADHD Assessment eToolkit) done by the same individual provide valid measures of treatment outcomes compared to pre-treatment.
Many of the symptoms seen in adolescence are like those seen during childhood but they can affect an adolescent's life in many different areas. Difficulties in school usually continue and often, because of increasing school challenges, become worse. Inattention, lack of focus, impulsivity and forgetfulness can impact assignments and grades. Even athletic and extracurricular activities can be negatively affected. Adolescence is also a developmental period where risk-taking can increase dramatically. Clinicians need to be aware of the very significant negative outcomes that can occur when ADHD during adolescence is untreated (see Accidents/Risks in Adolescence later in this chapter).
Adherence to medication and to psychosocial interventions can be very poor in adolescence. Studies indicate 48-90% of adolescents stop taking their medications  , though the use of once-daily dosing improves adherence . Psychoeducation is a very useful tool for augmenting adherence by making the adolescent a partner in treatment . Knowledge of the individual's acceptance level of their diagnosis will help determine if intervention is required to address resistance. Using motivational interviewing techniques can be helpful with adolescents who will not adhere to treatment .

# College/University Students
The prevalence of ADHD among post-secondary students is between 2-12% . Young people with ADHD attending university programs may present with varying histories, such as:
- Students already diagnosed and treated in childhood may want to adapt their ADHD treatment to their studying schedule. This may be a challenge as students may require treatment coverage further into the evening or night.
- Some students may have stopped taking their medication and may want to restart their treatment as they face increasing cognitive demands of the university curriculum.
- Similarly, some individuals who may never have been diagnosed before seek consult for the first time while facing difficulties coping with the high cognitive demands of university classes.
Young adults presenting for the first time for a diagnosis of ADHD should be carefully assessed. Some reports in the literature suggest a subset of students may exaggerate their symptoms to obtain accommodations/benefits or to obtain medications to enhance performance, to sell or to use for recreational purposes . A recent study found that some female college students endorsed having used ADHD specific stimulant outside a doctor's prescription for weight loss .
Life-time prevalence rates of non-prescribed stimulant use in college and university students range from 5%-43% .
Despite a minority of misusers, students with ADHD will benefit from access to treatments and accommodations. The CADDRA Assessment eToolkit includes an educational accommodation letter template and CADDAC provides a detailed chart of appropriate accommodations linked to specific impairments in the post-secondary environment on its website (www.caddac.ca).

# PRACTICE POINT
Information gathered from standardized rating scales help identify ADHD symptoms, comorbid disorders and associated impairments. If necessary, standardized cognitive evaluation focusing on attention and other executive dysfunction may help quantify IQ, identify specific cognitive dysfunction and, importantly, diagnose Specific Learning Disorders.
When assessing ADHD in post-secondary students, an assessment may require multiple visits and comprises a review of (when available):
- Parental/guardian reports of symptoms during childhood.
- School report cards.
- Reports from current collateral informants. Some reports suggest misuse or diversion of stimulants is associated with SUD and CD, so these conditions should be carefully screened for .
Additional school services and accommodations in the university setting can be very useful (e.g., separate testing environments, longer testing times, reduced homework and provision of a note taker).

# Adults
Many adults go undiagnosed and untreated for ADHD. In a study published by Kessler et al.,  the prevalence of ADHD in adults (20-to 64-year-olds) was 4.4%. Some adults may present to healthcare professionals seeking an assessment for ADHD with no prior diagnosis. This occurs for a variety of reasons, including:
- Parents of children who have recently been assessed for ADHD begin to wonder if they may have the same diagnosis.
- Individuals who have heard or read about ADHD in adulthood and can relate to the symptomatology.
- A subset of adults who have not experienced significant symptoms or struggles prior to adulthood. Lack of challenges prior to adulthood may be due to significant supports, structure and routines earlier in life, and/or an above average IQ . With increasing responsibilities and demands, and with diminished "scaffolding" in adulthood, many of these individuals begin to experience significant symptoms and associated impairment .
In adults with ADHD initially diagnosed during childhood, a significant number discontinue their medication management during adolescence . This may be due to medication side effects, independence needs, healthcare discontinuity, social stigma , or symptom remission . However, due to the re-emergence of symptoms and associated impairment in adulthood, they may seek re-assessment of their ADHD and choose to resume treatment.
Most adults with ADHD (85%) suffer from a comorbid mental health condition . Thus, many adults with undiagnosed ADHD may present to their primary care physician and/or mental health professional seeking treatment for what may appear to be a primary mood, anxiety or other mental health disorder. Others may get medical attention for substance use or high-risk behaviour consequences, trauma or unplanned pregnancies. It is important to know which of these individuals should be screened for possible underlying ADHD. Missing this diagnosis can result in years of trials with antidepressants, mood stabilizers and anxiolytics without adequate symptom response.
Examples of useful workplace accommodation and information for employees and employers can be found on the CADDAC website (www.caddac.ca). CADDRA has a template for requesting occupational accommodations in the eToolkit.

# Older adults
Results from a large epidemiological study have demonstrated that ADHD symptoms can persist in older adulthood, with an estimated prevalence of about 3% .
However, there is relative paucity of data available on the aging ADHD population compared to younger age groups. Small observational studies have characterized the presence, impact, and treatment of ADHD in adults over the age of 50 years .
Undiagnosed ADHD in older patients can lead to lifelong functional and psychosocial impairments. In addition, the presence of comorbidities including depression and cognitive impairment can make diagnosing an older patient's ADHD complex. Furthermore, diagnosis of ADHD in older adults can be tricky because some ADHD symptoms are seen in the normal aging process, or are similar to certain symptoms of minimal cognitive impairment or dementia, thus leading to the incorrect assumption that older adults with ADHD are undergoing a neurodegenerative disease process .
It is therefore crucial to raise clinician awareness about ADHD in older adults. Detailed history-taking (longitudinal cognitive difficulties since childhood) and neuropsychological testing may help the clinician to make a diagnosis of ADHD . In summary, diagnosis in older adults requires identification of past and current symptoms/impairments, and differential diagnosis should include other neuropsychiatric conditions. The first-line medications for ADHD recommended in these guidelines remain the treatment of choice for older adults when their medical condition permits their use. It is important to note that very few clinical drug trials have included participants with ADHD over age 65. However, appropriate treatment with specific medication for ADHD might improve functional outcomes for older adults with ADHD, including those with comorbid dementia . An important consideration in treatment is drug interactions since older adults often take multiple medications. Medication and psychotherapy trials with older adults are needed to determine best treatment approaches.

# IMPACT/FUNCTIONAL DISABILITY ACROSS THE LIFESPAN
ADHD can impact all aspects of an individual's life, both personally and systemically. In a 33-year follow-up study, children with ADHD were found to have a greater risk of poor long-term outcomes as adults in almost every aspect of life compared to their non-ADHD counterparts .
The core difficulties in executive functioning seen in many individuals with ADHD  cause varying degrees of functional impairment depending upon the demands made on the individual by their environment and the supports available. Variable factors include family and school or occupational resources, as well as personal responsibilities, coping strategies, cognitive capacity and reflective insight of the individual.
Individual -Regardless of academic, personal, occupational, professional or financial success, many individuals with ADHD struggle with low self-esteem . Some often describe negative beliefs or expectations of their own abilities. Some describe an "imposter complex" whereby they have trouble taking credit for their success. This may be due to lifelong inconsistent performance and a history of negative feedback for perceived failures.
Family -Due to the high heritability of ADHD  there is seldom only one individual with ADHD within a family unit. In addition, untreated ADHD may be a significant explanation for a higher rate of separation and divorce in these individuals . Other impacts on the individual or the family can include: parental stress; parental emotional/mental health problems; sibling conflict; disruption to family cohesion; and less time available to spend on family activities . In a survey of 500 individuals with ADHD compared to 501 matched controls it was found that the annual US household income losses due to ADHD were $77 Billion USD per year and up to $15,000 per household per year . The literature supports the fact that ADHD runs in families  and where appropriate, other family members should be screened or encouraged to seek out assessment. Parents, siblings and extended family members may have ADHD and therefore have problems with organization, consistency, impulsivity and emotional lability. In addition, having a child with a disability may increase the likelihood of substance abuse, depression and anxiety in parents . Parental psychopathology can have a significant impact on the parents' ability to structure, monitor and generally help their child . Identifying this psychopathology and referring the parents for appropriate treatment will improve the psychiatric state of the parent(s) and their parenting ability, and thus be of great help to the child or adolescent and their family. It is important for the parent(s) to be treated at the same time as the child or adolescent. This "all in the family" approach to intervention is good for the child/adolescent as it shows that the parent can empathize with their experiences. When parents learn skills to control their own lives, it is easier to institute structure in the child's life .
School -Individuals with untreated/undertreated ADHD are more likely to be expelled or be truant, may have lower grades than expected, and also disrupt others' education . This may impact the individual's future social and economic status.
Occupation -Adults suffering from ADHD have higher absenteeism and lower productivity in the job setting . They are also more likely to impulsively quit or change jobs, or be fired . Specific ADHD treatment may diminish this risk (87).
Healthcare and Society -A population-based, historical cohort study followed 4,880 individuals from 1987 to 1995 and compared the nine-year median medical cost per person: ADHD medical costs were US$4,306, whereas non-ADHD medical costs were US$1,944 (p<0.01) . Individuals with ADHD have a 33% increased rate of emergency room visits  and may be more vulnerable to motor vehicle accidents with some studies suggesting a rate that is two to four times as high . Compared to children without ADHD, children with ADHD may be more likely to sustain injuries that are severe, and that involve the head or multiple body regions . The increased rate of accidents in individuals with untreated/undertreated ADHD has economic impacts on the healthcare system, as well as economic and social effects within the family (e.g., reduced income, missing education) .

# ACCIDENTS/RISKS
Accidents/risk in childhood ADHD in children has been linked to a two times greater risk for accidental injuries of all types, for more severe injuries, as well as for repeated injuries . Comorbidity of ODD/aggression with ADHD in children is thought to exacerbate these risks .
Children admitted to hospitals due to accidental injuries are three times more likely to have ADHD (approx. 30%) than are children admitted for other reasons. Factors that have been associated with these elevated risks are inattention, impulsivity and risk-taking behaviours, motor incoordination, comorbidity with ODD/CD, anxiety, and depression, and parental characteristics such as reduced parental monitoring of the child's activities. Medication can decrease injuries .

# PRACTICE POINT
Promote safety in the home and outside, especially for the hyperactive/impulsive child. To reduce risks, children with ADHD may need supervision of activities, such as walking to school, that peers may not require.
Points to discuss with parents:
- Provide physical safety (e.g. safety proofing, ample outdoor places that can be safely used and supervised, opportunities for physical movement).
- Assure adequate supervision, and reinforce behaviours where the child shows risk management (e.g. wearing a helmet/protective gear, asking permission, wanting advice, following rules, reading instructions, showing good judgment).
- Children with ADHD benefit from physical activity and may find opportunities for success in play or sport.
- Balance must be struck between providing safe environments and overprotection.
- It is also important to create a calm, structured, positive approach to child rearing to not only optimize appropriate developmental progression, but also allow for a more acceptable response to limit setting.
- Above all, it is crucial that parents retain an enjoyable relationship with their child that encourages their self-esteem. Doing things that the child excels at or enjoys is very important. Parenting should include not only structure and guidance, but fun. The school must create a similar environment.

# Accidents/risk in adolescence
Adolescence is a developmental period when a significant percentage of individuals start to engage in activities that have associated risk . Adolescents who have ADHD are at higher risk than the general population for experiencing the negative outcomes of risky behaviours . Impulsivity, in particular, can negatively impact an adolescent's executive functioning. There is much evidence that untreated ADHD can lead to higher rates of accidents, school failure and dropout, driving accidents and family conflict/fighting .
Sexual activity starts for some during adolescence. Both male and female adolescents who have ADHD are at increased risk for early sexual activity, sexual transmitted diseases and multiple sexual partners . Females with ADHD are at risk of higher rates of teenage pregnancy compared to adolescents without ADHD . Information should be provided about risky sexual activities and use of birth control methods should be encouraged where appropriate.
Adolescence is frequently the time where experimentation with alcohol and drugs begins. Adolescents with ADHD have higher risk than the general population to start using earlier and to develop more severe difficulties with substances . Comorbidity of ADHD and SUD commonly starts in adolescence .
Abstinence from illicit drug use is ideal, though a harm reduction approach may be a useful option. Another group of substances that should be asked about are beverages containing excessive caffeine, including for example "energy drinks".

# Accidents/risk in adulthood
Many of the risky behaviours that are problematic in childhood and adolescence continue to impact individuals with ADHD into adulthood. In a recent study, the adjusted mortality rate ratio (MRR) was greater for individuals diagnosed with ADHD, and increased with delay in diagnosis. The adjusted MRR was 1.86 when diagnosis occurred before six years of age and increased to 4.25 when diagnosis was delayed to 18 years or older . The cause-specific mortality for suicide was significantly higher among ADHD cases (SMR = 4.83). This study concluded that childhood ADHD is a chronic health problem, with significant risk for mortality, persistence of ADHD, and long-term morbidity in adulthood.
Richards et al.  assessed negative driving outcomes in individuals with ADHD, reporting more driving anger and aggression expressed using vehicles, as well as less adaptive and constructive anger expression compared to peers without ADHD. College student drivers with ADHD rated themselves as more angry, risky, and unsafe behind the wheel, and reported more struggles with concentration and vehicular control .

# DRIVING
ADHD symptoms can negatively impact the ability to drive safely for both adolescents and adults . Not all patients with ADHD who drive have significant driving problems. However, the epidemiological data suggest that ADHD drivers as a whole have an increased risk . It is important that all adolescents with ADHD have driver training and that their driving risks be minimized (e.g. curfews, staying off major highways, absolutely no drugs or alcohol while driving). Driving assessments can be done and an example of such is the Jerome Driving Questionnaire (JDQ), which is provided in the CADDRA Assessment eToolkit).
Clinical studies indicate that young drivers with untreated or sub-optimally treated ADHD have between two to four times as many motor vehicle collisions and moving violations than a comparable non-ADHD population . These driving problems are seen independent of comorbidity. The problem profile commonly includes speeding, distractibility and driving anger or road rage. The presence of ADHD and comorbid substance use disorders magnifies driving risk .
Neurodevelopmental immaturities in executive functioning (resulting in problems with attention, impulse control and emotional regulation), combined with a lack of driving experience, can lead to problem driving styles in young people in general . On-road data demonstrates the benefits of long-term use of stimulant medication in reducing motor vehicle collisions in older adults .
Simulator and on-road observation studies suggest that methylphenidate, dexamphetamine and atomoxetine improve driving behaviours in ADHD populations . At the time of writing (March 2017) there are no current studies evaluating other agents for treating ADHD. Clinicians should monitor individual response to medications, both for improvement as well as worsening of driving abilities. For example, agents like guanfacine or clonidine may be sedative initially and worsen driving in the initial titration period. In addition, some medications may not last until late evening or adherence with the use of an "as needed" short-acting stimulant medication is particularly poor in the evening, which is the time of maximum driving risk for young drivers.
Restrictions on cell phone and manual transmission use, as well as on nighttime and weekend driving, may all improve driving performance. Psychosocial and legislative interventions may prove to be more effective preventative public health measures in the long run .

# EVALUATION OF DRIVING RISK AND DOCUMENTATION
Discussion with young drivers and their families should include information on functional impairment and driving risks . Problems with speeding, following too close, road rage, inattention and distractibility when driving should be reviewed. When developing a therapeutic alliance with a family, it may be useful to encourage contracts between young drivers and their families where adherence with medications and other issues such as good school performance are exchanged for access to a motor vehicle. Documentation of discussions regarding driving safety, along with use of a driving style and behavior assessment, would demonstrate that the clinician is exercising due diligence for their ADHD patients around driving safety issues. The Canadian Medical Association (CMA) Guidelines on Fitness to Operate a Motor vehicle continue to remind physicians that if ADHD drivers have a demonstrated problem with driving and are non-compliant with treatment recommendations, doctors have a duty to report their concerns to the Provincial Ministries of Transportation . Reporting in Alberta, Quebec and Nova Scotia is discretionary . The latest CMA guidelines continue to recommend the same reporting requirements and have an updated reference list on ADHD and driving.

# CHAPTER 4: PSYCHOSOCIAL TREATMENT OF ADHD
Until recently, symptom control was the main priority in the assessment and treatment of ADHD . In recent years, the clinical focus has shifted towards functional impairments and outcomes, with improvement of overall life quality as the main goal . ADHD can impact many aspects of an individual's daily life such as social and emotional functioning, academic/work-related success, relationships, marriage, family life and even physical health . This is true for individuals with ADHD across the lifespan. Generally considered to be a chronic lifetime disorder, ADHD requires a comprehensive, collaborative and multimodal treatment approach  tailored to meet the unique needs of the person with ADHD.
Research studies and clinical experience show that a multimodal approach (incorporating psychosocial interventions together with medication) improves not just core ADHD symptoms but the overall quality of life by improving the resultant functioning impairments . Medications are an important aspect of treatment and assist the facilitation of changes in these areas by improving focus, self-regulation and decreasing impulsivity/hyperactivity and thus allowing the individual to use psychosocial strategies more effectively .
Psychosocial treatment is the therapeutic approach preferred by many individuals over medications and is recommended as a first line for preschoolers by the American Academy of Pediatrics and the Choosing Wisely Canada campaign (choosingwiselycanada.org). Psychosocial interventions play a particularly crucial role during key life transitions, for instance in the transition from adolescence to adulthood . It is important to incorporate a patient-/familycentered approach to ADHD treatment, by considering individual/family treatment preferences  Although front-line clinicians may see time constraints and perceived lack of expertise as barriers to implementation of psychosocial treatments , these individuals are in fact ideally placed to assess and provide treatment for ADHD beyond traditional pharmacological approaches. Primary care practitioners are in the unique position of being able to diagnose, treat and follow individuals with ADHD across the lifespan . They can provide or support some of these interventions in a timely manner either on their own (with community resource supports) or in co-ordination with other medical specialists, health-care providers and professionals from the educational system.
A solid therapeutic alliance is best achieved by spending time listening to a patient's concerns and understanding their perspective and goals. CADDRA wishes to highlight this principal as being the core foundation for all effective treatment approaches.

# PSYCHOEDUCATION
The overall purpose of psychoeducation is to educate and empower patients and their families by providing information on ADHD (e.g., impact on daily functioning, treatment options, strategies for optimizing functioning).

# PRACTICE POINT
CADDRA Guide to ADHD Psychoeducation can be downloaded from the CADDRA website from the Resources section. This guide provides a quick overview of the components of psychoeducation along with a summary of strategies and interventions that can be recommended to individuals with ADHD and their families.

# Key Elements of Psychoeducation Discover
Find out what the patient and family already know, or think they know, about ADHD . This may help guide your approach to diagnosis and treatment.

# Demystify
Take the time to discuss some of the societal myths commonly associated with ADHD. For example, the following myths are adapted from the "Take Ten Series" from the CanLearn Society, Calgary. 

# MYTHS FACTS
ADHD is not a real condition ADHD is a neurobiological condition that is associated with inattention, hyperactivity and/or impulsivity, along with several related difficulties, inappropriate for an individual's age.

# ADHD is over-diagnosed
A US 2014 national survey found that healthcare practitioners are carefully diagnosing children. The vast majority (9 out of 10) of the 2,976 children diagnosed with ADHD had been diagnosed by practitioners using best practice guidelines . Possible explanations for increased diagnosis of ADHD include improved healthcare practitioner and parental awareness; more screening by pediatricians and other primary care givers; decreased stigma about ADHD; availability of better treatment options, and more awareness of suspected environmental causes such as prenatal exposure to toxins or high blood lead levels .

# All children with ADHD have disruptive behavioural problems
Approximately 50 percent of children with ADHD demonstrate significant problems with disruptive behaviour .

# ADHD results from ineffective teaching and/or poor parenting
ADHD is primarily biological and genetic in its origins. Environmental factors such as teaching and parenting quality, however, can minimize or intensify the difficulties experienced by an individual with ADHD .

# Children with ADHD can never pay attention or complete their work
Inconsistency is a pervasive characteristic of ADHD. Sometimes, and under some circumstances, individuals with ADHD can focus and concentrate, while at other times they experience extreme difficulty. They are, for example, often able to hyper focus on stimulating activities, like video games, or creative activities such as Lego or drawing.

# CONTINUED...

# All children with ADHD are hyperactive
A person with ADHD may not necessarily demonstrate hyperactivity. In fact, some individuals with ADHD may appear to lack energy and seem quiet and reserved.

# ADHD only occurs in boys
Boys are four to nine times more likely to be diagnosed ; however, the disorder occurs in both boys and girls. Girls are more prone to inattentive type ADHD , which is marked by disorganized and unfocused behaviour rather than the disruptive, impulsive conduct typically seen in boys. Girls with ADHD tend to have higher rates of overall distress, anxiety and depression compared to boys with ADHD .

# Food allergies, refined sugar, food additives and poor diet cause ADHD
The actual correlation between ADHD and diet has not been proven . Good nutrition and general health are always important. An unhealthy lifestyle, including poor diet, can influence attention and functioning .

# Medication alone can manage ADHD
While there is no cure for ADHD, medication can have positive effects on symptoms of inattention, impulsivity and hyperactivity. A "multimodal" or comprehensive approach is most beneficial and includes appropriate diagnosis, personal and family understanding of the disorder, behavioural interventions and educational supports.

# Individuals with ADHD are lazy or lack willpower
Everyone finds it easier to focus on a topic or activity that catches their attention. Many people with ADHD have some domains of activity (such as sports, music, video games, art, mechanical activities and areas of work) in which they can focus very well. As a result, their inability to focus in other areas is often misunderstood.
There is a test that can diagnose for ADHD ADHD is a clinical diagnosis that should be arrived at through a comprehensive evaluation of the history and presentation. This is true of many other medical conditions (e.g. migraine).

# Everyone has ADHD because everybody is inattentive sometimes, especially these days.
The core symptoms of ADHD can occur in everyone occasionally (e.g. forgetting items). People with ADHD, however, experience significantly greater numbers of these symptoms (meeting a threshold of at least 6/9 symptoms for children, 5/9 for adults (17+)), with greater frequency and more significant difficulties and impairment (e.g., job loss, academic underachievement).

# Instill Hope
Families will respond positively when told evidence-based treatments and interventions do exist. This in turn will promote the therapeutic alliance and a positive outcome.

# Educate
The first step is to educate individuals and families about the nature of ADHD and its symptoms. If relevant, explain the concept of emotional dysregulation. This refers to the fact that many individuals with ADHD can experience difficulty selfmodulating and regulating emotions, often referred to as "a short fuse". They can impulsively over-react verbally or physically, causing significant conflicts.
Explain the rationale behind your treatment approach (e.g. the use of pharmacological or psychosocial interventions and the risks and benefits of each). For example, ADHD medications can improve focus and decrease impulsivity/hyperactivity, allowing individuals to make better use of psychosocial strategies . Provide handouts and information on relevant websites, community resources, parent training and support/social skills groups, etc.

# Empathize