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“[Is] ‘complex’ attention-deficit/hyperactivity disorder more norm than exception?”1

-Irene Koolwijk, MD, et al

“[Is] ‘complex’ attention-deficit hyperactivity disorder more norm than exception?”1

-Irene Koolwijk, MD, et al

Attention-deficit/hyperactivity disorder (ADHD) in pediatric patients has traditionally been viewed as a discrete behavioral condition.

While a certain proportion of children with ADHD express symptoms of ADHD alone (often described by your peers as “simple ADHD”), we now know that this is overwhelmingly the exception rather than the norm.1-3

Growing evidence supports a new paradigm of complex ADHD that underscores the need for effective and proactive management of the disease early in childhood.4-7

A new paradigm of ADHD

Growing evidence support a paradigm of ADHD as a complex disorder, with neurobiologic vulnerabilities, and various associated comorbidities.1-4

A new paradigm of ADHD

Growing evidence support a paradigm of ADHD as a complex disorder, with neurobiologic vulnerabilities, and various associated comorbidities.1-4

ADHD is now conceived as a complex genetic trait with a heterogeneous presentation based upon a phenotype ranging from mildly to severely affected.8


Genetics has also been shown to contribute to the onset, persistence, and remission of ADHD9—and may account, in part, for the co-occurrence of ADHD with emotional dysregulation.2

More recent research also points to ADHD as an impairment of executive function that negatively impacts the brain’s cognitive architecture.2 This has far-reaching consequences in the domains of:
School/education
Home/family life
Emotional development
Peer interaction

Sequencing of ADHD symptoms

While ADHD symptoms may be present in other neuropsychiatric conditions,
ADHD is often the first disorder to appear.

Sequencing of ADHD symptoms

While ADHD symptoms may be present in other neuropsychiatric conditions, ADHD is often the first disorder to appear.

Comorbidities such as depression, anxiety disorders, and conduct disorders tend to develop later.2

Such sequencing of symptoms has led some to suggest that executive functioning deficits in individuals with ADHD may leave them more vulnerable to future psychiatric illness.2 This again underscores the need for proactive and effective treatment options early in the ADHD disease process.

More to ADHD

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References: 1. Koolwijk I, Stein DS, Chan E, Powell C, Driscoll K, Barbaresi WJ. “Complex” attention-deficit hyperactivity disorder, more norm than exception? Diagnoses and comorbidities in a developmental clinic. J Dev Behav Pediatr. 2014;35:591–597. 2. Brown TE. Developmental complexities of attentional disorders. In: Brown TE, ed. ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults. Arlington, VA: American Psychiatric Publishing Inc; 2009:3–23. 3. Shaw P, Polanczyk GV. Combining epidemiological and neurobiological perspectives to characterize the lifetime trajectories of ADHD. Eur Child Adolesc Psychiatry. 2017;26(2):139-141. 4. Banaschewski T, Becker K, Dopfner M, Holtmann M, Rosler M, Romanos M. Attention-deficit/hyperactivity disorder. Dtsch Arztebl Int. 2017;114(9):149–159. 5. Hervas A, de Santos T, Quintero J, et al. Delphi consensus on attention deficit hyperactivity disorder (ADHD): evaluation by a panel of experts. Actas Esp Psiquiatr. 2016;44(6):231-243. 6. Jensen CM, Steinhausen H-C. Comorbid mental disorders in children and adolescents with attention-deficit/hyperactivity disorder in a large nationwide study. Atten Defic Hyperact Disord. 2015;7(1):27-38. 7. Reale L, Bartoli B, Cartabia M, et al. Comorbidity prevalence and treatment outcome in children and adolescents with ADHD. Eur Child Adolesc Psychiatry. 2017;26(12):1443-1457. 8. Acosta MT, Arcos-Burgos M, Muenke M. Attention deficit/hyperactivity disorder (ADHD): complex phenotype, simple genotype? Genet Med. 2004;6(1):1–15. 9. Faraone SV, Asherson P, Banaschewski T, et al. Attention deficit/hyperactivity disorder. Nat Rev Dis Primers. 2015:1:1–23.