Afterword to Exploring Complex Attention Deficit Hyperactivity Disorder Through Challenging Cases

ELIZABETH A. DIEKROGER & JASON M. FOGLER, GUEST EDITORS OF THE CASE SERIES

Attention-deficit hyperactivity disorder (ADHD) is an extremely common disorder affecting 5% to 8% of children worldwide,¹ with approximately 10% of children in the United States carrying a current diagnosis of ADHD.² As we strive to better understand ADHD and its impact, it has become clear that it is not only a disorder of childhood but 1 that continues on into adulthood with far-reaching consequences for many.³ The challenges associated with ADHD often come to professional attention for school-age children, and many clinical researchers have accordingly targeted this critical period of development.^4,5

Given its prevalence and pernicious outcomes across the life span,⁶ and high rates of co-occurrence with other medical and mental health conditions,² there remains a persistent and undermet need for collaborative care across disciplines.^7,8 The Complex ADHD Clinical Practice Guideline (CPG) was published in 2020 in recognition of the fact that ADHD occurs 60% or more of the time with other conditions and affects functioning across the entire life span.⁹ The ADHD Special Interest Group (ADHD SIG) of the Society for Developmental and Behavioral Pediatrics was a significant driver of the CPG's production and developmental process—including vetting its extensive evidence base¹⁰—and continues to be an active force in the CPG's dissemination. To date, the ADHD SIG has created infographics and online toolkits explaining the guideline and presented workshops highlighting the guideline at the 2022 and 2023 SDBP meetings.

This case series represents the next chapter in this dissemination effort. The cases—some of which were previewed during our workshops at the Society's Annual Meeting in 2022 and 2023—touch on the many types of complexity that affect the treatment of ADHD, including coexisting medical and mental health conditions, psychosocial barriers to care, and cases involving elements of all 3. ADHD plays a different role in each of these cases and the goal of the case series is to describe the variety of impacts it may have on children's health. Drawing on the expertise of interprofessional clinicians, persons with lived experience, and their families, these cases are intended to bring the CPG to life, and it is the hope of the ADHD SIG and those involved in writing these cases that they will provide insight into the CPG and how to implement it into clinical care.

The medical cases in the series address situations in which the medical condition interferes with the clinical team's ability to treat ADHD or the symptoms of the medical condition mimic or mask the presenting ADHD symptoms. Mittal et al.¹¹ describe the case of a child with eosinophilic esophagitis (EOE) whose untreated ADHD leads to impulsive behaviors that both exacerbate the EOE symptoms and the family's ability to adhere to recommended treatment. In their case involving absence seizures, Jerskey et al.¹² remind us of the importance of remaining vigilant for medical conditions that can mimic the symptoms of ADHD or may be overshadowed by the existing ADHD diagnosis. Finally, Campbell et al.¹³ sensitively address the layered approach required to treat a child with ADHD and repaired Tetralogy of Fallot, including intensive monitoring for adverse medication effects, adapting psychosocial treatments and close collaboration with specialists.

One of the core issues addressed by the CPG is the management of co-existing psychiatric conditions, specifically the nuanced approach to complex ADHD management required to: (1) discriminate between, prioritize and appropriately target overlapping symptoms; and (2) balance validation of parent and patient concerns while adhering to standards of care. For example, although the combination of ADHD, autism, and anxiety is common in many developmental-behavioral health care practices, the case by Dafner-Deming et al. is complicated by the need to collaborate with divorced parents, enlisting them as data collectors to establish trust and create buy-in for evidence-based (cognitive-behavioral) psychotherapy.¹⁴ We also see this tension playing out in Lackey et al.¹⁵ discussion of a case of co-occurring ADHD and tics and in Potts et al.¹⁶ discussion of scaffolding a depressed teen's motivation to engage in telemental health during the COVID-19 pandemic.

ADHD is commonly associated with high levels of psychosocial complexity, which is also targeted by the CPG. The series contends with nontraditional family structures,¹⁷ cultural brokering,¹⁸ structural racism in the public school system,¹⁹ and barriers to care access internationally.²⁰ In these cases, medical care simply cannot happen without engaging with the patients' intersecting identities and the challenges inherent to those identities. Although in most cases, the clinician is focusing on the whole family, 2 of the cases specifically highlight working with and supporting the teen patient's developing autonomy. Simon et al.²¹ describe the far-reaching impact of cultural biases in the case of a teen with co-existing marijuana use, ADHD and school difficulties; Meneses et al.²² address self-determination, including reproductive autonomy, in the case of a young woman with Smith-Magenis syndrome and intellectual disability.

ADHD contributes to a wide range of challenges and the CPG provides a framework for treatment prioritization and appropriate management across different clinical presentations. When the guideline was first published, the workgroup acknowledged the need for advocacy and to fill knowledge gaps; toward this end, this case series offers practical examples for applying the guideline requested by our membership. We hope you enjoy the cases and find them to be helpful both in clinical practice and in understanding and using the Complex ADHD CPG.