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Attention-decit hyperactivity disorder (ADHD) is a practices and early unwanted pregnancies, substance
neurodevelopmental disorder with core symptoms use, relationship difculties, marital problems, traf-
that include hyperactivity, impulsiveness, and inat- c violations, and car accidents. Irritability of chil-
tention, and it is the most common psychiatric dis- dren with ADHD has been a key symptom that
order among children and adolescents. These core clinicians and researchers have used to evaluate the
symptoms are continuously recognized throughout developmental condition of children with ADHD.
the day from childhood to adulthood. Furthermore, ADHD is sometimes a chronic disorder that occurs
children with ADHD from childhood to adulthood over a long period, increasing the family burden of
might also have various comorbid psychiatric disor- these children (including health-care costs), which
ders. Recently, bipolar disorder and disruptive mood will increase with aging for unremitted children with
dysregulation disorder, a new clinical issue, have ADHD. Therefore, clinicians should evaluate not
been discussed as comorbid disorders or differential only the mental condition of the child but also the
disorders associated with ADHD. Furthermore, family burden. Children with ADHD should be trea-
comorbid disorders of ADHD are related to quality ted during childhood to reduce their clinical symp-
of life and family burden. Children with ADHD toms and family burden.
have poorer long-term outcomes than controls with
respect to: academic achievement and attainment, Key words: attention-decit hyperactivity disorder,
occupational rank and job performance, risky sexual burden, child, family, irritability.
ADHD neurocognitive heterogeneity model. The However, during the clinical evaluation, it is also
model included executive dysfunction, delayed important to be aware that these children may have
rewards and delay aversion, and temporal proces- problems in a variety of areas, such as family rela-
sing. They advocated the possibility that specic tionships, school life, friendships, academic achieve-
training would be more effective if it was targeted ment, emotions in adulthood, and work, the
and tailored for children with problems in the exec- severity of which is associated with ADHD core
utive domain. Training that strengthens temporal symptoms.710,2933 Evaluation of the childs behav-
processing or delay-related functions might be more ior across various periods of the day and a trial of
effective for patients with these types of decits. appropriate treatments is important for a good long-
However, the model might be insufcient for under- term prognosis of children with ADHD along with
standing biological dysfunctions of children with the family burden.34 For clinicians, evaluation dur-
ADHD. Remarkable ndings have been reported in ing different periods of the day is important as it
studies of the prefrontal area of the brain in children allows them to characterize the childs daily life
diagnosed with ADHD. Compared with a control through their relationships with their friends and
group, the delay in cortical maturation was most parents.9,29,31,34
prominent in the prefrontal regions that are impor- Therefore, this review discusses clinical issues in
tant for the control of cognitive processes, including the developmental condition and family burden of
attention and motor planning.5 The cortical matura- children with ADHD.
tion delay in children with ADHD was most promi-
nent in the lateral prefrontal cortex.
Neuroimaging and clinical follow-up studies sug- DEVELOPMENTAL CONDITION
gest that the developmental condition of ADHD OF CHILDREN WITH ADHD
might spontaneously change from childhood to Presumably, many children with ADHD have some
adulthood. Many follow-up studies reported that subclinical symptoms, and their lives at school and
ADHD is a chronic disorder and that symptoms home continue without difculty into adolescence
often persist into adult life.6 Further, these symp- or adulthood. Probands with remitted ADHD have
toms are continuously recognized throughout the better mental health outcomes. The developing con-
daytime from childhood to adulthood.710 The rate dition of ADHD is demonstrated by biological dys-
of persistent ADHD is approximately 15% at functions, core symptoms, psychological problems,
25 years, with a partial remission rate of approxi- behaviors problems, and the environmental condi-
mately 65%.11 Children diagnosed with ADHD have tion (Fig. 1). In early childhood, children with
poorer long-term outcomes than controls in terms ADHD might only suffer from intellectual disabil-
of: academic achievement and attainment, occupa- ities and/or autism spectrum disorder (ASD). By
tional rank and job performance, risky sexual prac- later childhood, intellectual disabilities, anxiety dis-
tices and early unwanted pregnancies, substance use, orders (AD), tic disorders, oppositional deant dis-
relationship difculties, marital problems, trafc order (ODD), and disruptive mood dysregulation
violations, and car accidents.1223 disorder (DMDD) are common comorbid disorders
These studies were used in the current diagnosis of children with ADHD and conduct disorder (CD),
and treatment guidelines for ADHD, which are major depressive disorder (MDD), and bipolar dis-
widespread in the pediatric and psychiatric order (BD) occur more in adolescents. Finally, a few
eld.2427 When following the guidelines, a child children with ADHD might mature into adults with
psychiatrist usually treats children with ADHD using personality and/or substance use disorders.
a combination of psychosocial treatments and Clinically, these poorer outcomes of children with
pharmacotherapy.2428 When using the guidelines ADHD might be related not only to ADHD core
to evaluate and diagnose ADHD, a child psychiatrist symptoms, such as hyperactivity, impulsiveness, and
relies upon a treatment strategy of gathering infor- inattention, but also other psychiatric symptoms,
mation about the childs behaviors (hyperactivity, such as anxiety, tic, irritability, depressive mood,
impulsiveness, and inattention), the parents com- conduct problems, and substance use. Those adults
plaints, information obtained from medical and who have had ADHD since childhood might also
school records, and examination in a clinical setting. have various comorbid psychiatric disorders, such as
Figure 1. Clinical condition and core symptoms of attention-decit hyperactivity disorder (ADHD).
AD, MDD, BD, substance use disorder, ODD, CD, quantitative failure of communication and persist-
and personality disorders.29,3539 ence; it is one of the most common developmental
disorders. It has been suggested that children with
ASD have problems in numerous elds, including
ADHD WITH ASD family relationships, school life, and friendships;
In children with ADHD, there is a familial trait that their families also suffer a signicant burden for
correlates with ASD, CD, ODD, and language and their children.47,48 Core ADHD symptoms are com-
motor disorders.40 The onset of ASD symptoms is mon among individuals with ASD/PDD.4245
usually earlier than ADHD symptoms,41 although ADHD is one of the comorbid disorders associated
both ADHD and ASD are common neurodevelop- with ASD under the diagnostic criteria of ASD in the
mental disorders. In the clinical experience of many DSM-5.
child psychiatrists and pediatricians, it is common In clinical elds, ASD is usually treated with psycho-
knowledge that many children with pervasive devel- social therapy.49 However, some children with ASD
opment disorder (PDD) also exhibit hyperactivity, have ADHD symptoms of hyperactivity, impulsive-
impulsiveness, and inattention.4245 The diagnosis ness, inattention, and conduct problems. If the ADHD
criteria of ASD was declared when the DSM-5 was symptoms are more severe than the ASD symptoms,
published in 2013.46 The criteria of ASD dened the child psychiatrist or pediatrician will choose a
autistic symptoms; it was a revision of the PDD cri- treatment that focuses on the ADHD symptoms at
teria that was dened in the previous 1978 publica- the same time or before treating the ASD symp-
tion (DSM-IV-TR). ASD is a neurodevelopmental toms. In some cases, parents of children with PDD
disorder with core symptoms of qualitative and have also struggled with ADHD core symptoms.50
ODD include irritability and temper outbursts. with these symptoms may be misdiagnosed, undiag-
However, these two disorders differ in severity, dura- nosed, or overdiagnosed. However, some symptoms
tion, and pervasiveness/impairment. In community demonstrate a different developmental course over
samples, approximately 70% of children with time. In early childhood, compared with children
DMDD met the criteria for ODD, but less than 40% with ADHD, children with BD have brief and
with ODD met DMDD criteria.65 Thirty-nine out of extended elevated moods and a decreased sleep pat-
179 children (21.8%) with ADHD had comorbid tern. Children with BD often have changes in appe-
DMDD. Children with ADHD and DMDD had a tite and have more physical complaints than those
high prevalence of ODD (89.7%) and any of the AD with ADHD.75
(41.0%).68 DMDD is characterized by chronic and consistent
When comparing the criteria of DMDD and irritability, whereas irritability in BD is episodic,
ADHD, both disorders have similar clinical symp- representing a change from the persons usual
toms, including irritability and a decreased attention state.65 BD and DMDD have been discussed as
span. Clinically, temper tantrums in children with comorbid disorders or differential disorders associ-
DMDD have been misdiagnosed as behavioral pro- ated with ADHD.7279
blems because of the impulsiveness associated Simonoff et al. demonstrated the rst study of
with ADHD. behavioral and cognitive correlates of severe mood
Children with mood regulation problems are par- problems in ASD.80 Severe mood problems in chil-
ticularly difcult to treat.69 Mood dysregulation dren and adolescents include high levels of irritabil-
included infant temperament, irritability, temper ity, often manifested by temper tantrums as well as
tantrums, and oppositional behaviors. By the 4-year a low and labile mood. Another study addressed the
follow up, only 40% of children met the strict SMD etiology of mood dysregulation symptoms, most
criteria; however, most continued to display clini- specically the extent to which these are best con-
cally impairing symptoms and signicant impair- ceptualized as part of the spectrum of juvenile BD,
ment that warranted psychiatric treatment. These ADHD, or as a separate syndrome.73 Furthermore,
ndings provide evidence for the course of irritabil- the severity of autism and mood dysregulation are
ity, with implications for DMDD.70 strongly associated.80 Mikita et al. found that highly
Important distinctions between pediatric BD onset functional boys with ASD had more severe irritabil-
will be discussed relative to other childhood disor- ity than controls. Their pattern of irritability symp-
ders, including DMDD, ADHD, MDD, dysthymia toms closely resembled that of boys with SMD.
and other disruptive behavioral disorders, AD Irritability is associated with distinct biological
(including post-traumatic stress disorder), psychotic responses to stress.81
disorders, ASD, substance use disorders, and border-
line personality disorder.71
Some studies have shown that children with BD FAMILY BURDEN OF CHILDREN
have chronic irritability, and adults with BD in their WITH ADHD
childhood might be diagnosed as having DMDD/ ADHD symptoms in children are related to the fam-
SMD.72,73 Currently, many children with DMDD are ily burden and comorbid disorders of ADHD as par-
diagnosed with BD, despite the lack of distinct ents become distressed in their struggle with
mood episodes.64 Furthermore, a family history of children with ADHD.8285 Compared with the nor-
BD increases the risk for DMDD; the core symptoms mative population sample, parents reported that
of DMDD associated with mood and behavioral dis- children with ADHD experienced challenges
orders in youth increase the risk for developing BD throughout the day, from morning until bedtime, at
as an adult.63 Clinical discussions demonstrate that home and at school.13 Parents reported that chil-
DMDD/BD are comorbid or differential disorders in dren with ADHD consistently displayed more
children with ADHD. demanding, noisy, disruptive, disorganized, and
Additionally, studies of ADHD and BD show that impulsive behaviors.13 ADHD has a substantially
both disorders often have the same symptoms of negative impact on their daily functioning and aca-
impulsivity, hyperactivity, and a decreased attention demic achievement at home and at school.86
span.74,75 BD and ADHD often co-occur and are a The ADHD rating scale (ADHD-RS) and Child
chronic and lifelong illness.7679 Therefore, children Behavior Checklist (CBCL) have been most widely
used for the evaluation of ADHD to assess core Some questionnaires that target the parents stress
symptoms of ADHD emotional, behavioral, and sex- or burden have been used in the clinical eld. These
ual problems of children by the parent.77,87 How- questionnaires measure the frequency and severity
ever, those questionnaires do not include an of a parents stress.
assessment of the difculties associated with daily Recently, the Questionnaire-Children with Dif-
functioning or an evaluation of the patients status culties (QCD) has been used to evaluate parents
during specic periods of the day. perceptions of their childs daily behaviors during
According to a previous study, parents stress is specic periods of the day, such as the morning,
related to reports of child behavior 1 year later, their during school, after school, in the evening, and at
strain of missing work because of their childs pro- nighttime.8890 The QCD is also practical for sharing
blems, and feeling sad as a result of their childs pro- information among caretakers because it enables the
blems.58 In the early morning or before going to evaluation of life functions during specic periods
school, children with ADHD would typically of the day.29,8991
promptly get out of bed and groom themselves, Usami et al.34 used the QCD to address the peri-
which included washing their face, brushing their ods of the day that were more worrisome for parents
teeth, and getting dressed. They would not usually of children with ADHD than for parents with typi-
behave in an age-appropriate manner at breakfast. cally developing children.34 Elementary and junior
Before going to school they would get into trouble high school students with ADHD and typically
or have quarrels with their parents or siblings. At developing controls were enrolled. The QCD score
school, the children with ADHD would behave well for the ADHD group was signicantly higher than
in class, although they would usually have few that for the typically developing group. In the eve-
friends who accepted them. Because teachers would ning, ADHD core symptoms and ODD behaviors
often scold these children, they would usually be for boys and girls with ADHD were more severe
unlikely to discuss events that happened at school than at any other time period. Furthermore, at night,
with their parents. They would often struggle with inattention and ODD symptoms of girls with ADHD
their homework. Once the parents or siblings were more of a family burden than those of boys.
returned home, the children with ADHD would These results determined that parents perceptions of
choose not to enjoy family time and would con- their childrens ADHD symptoms were dependent
stantly quarrel with their family. They would not on the time of day. Further, the parents perceptions
converse in a calm manner during dinnertime con- were not dependent on their childrens grade but on
versations. Parents would feel uncomfortable being their sex, their symptoms, and the time of day.
with their children with ADHD when engaging in ODD behaviors comorbid with ADHD rather than
public activities, such as going out or shopping. pure ADHD symptoms may also be associated with
During the evening, these children would frequently family burden.
be engaged in playing, studying, cramming for Sasaki et al.50 investigated the behavior of elemen-
school, taking private lessons, and playing sports tary and junior high school students with PDD
with their friends. Older children with ADHD would using the QCD. The QCD scores for children with
not be able to follow instructions, such as brushing PDD were signicantly lower than those for children
teeth or changing clothes at night. Therefore, parents from the community sample. Family burdens of
with children with ADHD would often struggle. The children with PDD were more signicantly corre-
children would often lack self-condence, would lated with ADHD core symptoms and ODD beha-
not be socially accepted by others, and would be viors than were those of children with autistic
emotionally unstable. symptoms. Children with PDD experienced greater
Children with ADHD have difculties during difculties in completing basic daily tasks. Moreo-
daily activities. They often have many quarrels in ver, the difculties of PDD, ADHD core symptoms,
their home and at school, and they cannot follow and ODD behaviors combined in children make it
caregiver instructions. ADHD symptoms sometimes necessary to assess all diagnoses before any therapy
disturb daily activities, such as homework, family for PDD is initiated. This ensures that results are cor-
routines, and playing with other children. All rela- rectly evaluated.
tionships between children with ADHD and their Given that children with ADHD are at risk for
family are also negatively affected.13 subsequent adverse outcomes later in life, such as
lower academic achievements, interventions should Although considered to be a highly familial disor-
focus on their behavioral and educational develop- der, ADHD heritability estimates of 6080% high-
ment. These adverse outcomes induced a family eco- light the considerable role that environmental
nomic burden from childhood to adulthood. factors may still play in disorder susceptibility.
The family economic burden of children with Recently, adults with ADHD have been discussed in
ADHD has become a very serious issue; ADHD in several research papers.
childhood increases the risk of low socioeconomic As expected, childhood ADHD has a higher preva-
status in adulthood.92 The family economic burden lence than adult ADHD.98 Childhood prevalence
of children with ADHD includes the costs of comor- has been associated with childhood comorbid disor-
bidities, accidents, loss of a job, criminality, trans- ders, neurocognitive decits, polygenic risk, and
portation to a hospital, and effective drugs. residual adult life impairment. Adult prevalence has
Certainly, children with comorbid disorders have been associated with adult substance dependence,
more accidents and injuries and have higher health- adult life impairment, and treatment contact.98
care costs than those without comorbid disorders. Symptoms often persist into adulthood, with a prev-
The economic burden of a child with ADHD alence of 2.55% in adult populations. Twin studies
increases as the child ages.80 The 2004 medical costs in childhood consistently report a high heritability
of children with ADHD were higher than the annual of 7080%, whereas studies in adult samples show
medical costs in controls without ADHD (difference only a moderate heritability of 3040% when esti-
ranged from $207 to $1560).93 During adulthood, mated from self-ratings.99,100 In one study, the
increased medical costs among adults with ADHD childhood and adult ADHD groups comprised virtu-
compared with those among controls ranged from a ally non-overlapping sets; 90% of adult ADHD cases
difference of $2158 to $4178.93 Another study esti- lacked a history of childhood ADHD.99 Also, the
mated a potential public health-care cost for ADHD adult ADHD group did not show neuropsychologi-
medicines in Ireland based on their current prescrib- cal decits in childhood or adulthood, nor did they
ing patterns.94 Further, a longitudinal study show a polygenic risk for childhood ADHD.100
(at 14 and 25 years) in the UK investigated associa- These results indicate that the developmental condi-
tions between preschool hyperactivity and average tion of ADHD might be affected not only by biolog-
medical costs up to late adolescence and young ical factors but also by environmental factors.
adulthood.95 Preschoolers with hyperactivity had a Furthermore, ADHD and related neurodevelop-
17.6-fold higher average medical cost than the con- mental disorders are familial and heritable.97 The
trol group. Preventative approaches targeting early results from multivariate twin analyses suggest that
hyperactivity may reduce health-care costs. the heritability of ADHD, ODD, and CD are 0.82,
Further, costs of parenting children with ADHD 0.61, and 0.74, respectively, and that ADHD shares
include not only the cost for health care but also the most of its genetic liability with ODD and CD. Thus,
replacement costs of lost articles, such as misplaced these ndings argue for a common biological risk
video games, trading cards, bags, books, and glasses. underlying these commonly comorbid externalizing
Public and professional awareness campaigns are behavior problems and cognitive decits. The resid-
required to ensure that families get the benets and ual genetic variance provides preliminary support
that the cost does not become a barrier to treatment that additional genetic inuences underlying ODD
and improved outcomes. and CD are independent of ADHD.101
health conditions and severe physical disorders, current treatment and 3540% stated that their
ADHD has a comparable overall impact on the childs ADHD symptoms needed to be more effec-
quality of life.102 Increased symptom level and tively treated during the afternoon and evening.9
impairment predicts poorer quality of life. ADHD Stimulants (MPH) and non-stimulants (ATX and
has a substantial negative impact on daily function- guanfacine) are widely used worldwide and their
ing and achievement in various elds.1223,86 It also effectiveness and adverse effects for children with
negatively impacts families.103 ADHD have been extensively discussed.112114 Espe-
The MTA study demonstrated the gold standard in cially, stimulants are the long-acting MPH and
the treatment of ADHD in that children who received extended-release MPH. There is good evidence that
combined medication and behavioral interventions treatment with MPH and ATX is effective in improv-
had better outcomes than children who received ing some of these outcomes and can also improve
the usual community treatment.52 However, in a family functioning.115117
clinical setting, several guidelines for the treatment A large naturalistic study was performed from
of ADHD indicate that psychosocial treatments are 2007 to 2012 to assess the type and frequency of
more important than pharmacotherapy.25,26,104,105 adverse events in 1350 and 753 children with
The International Association for Child and Ado- ADHD (aged 618 years, mean age 10.7 2.8
lescent Psychiatry provides treatment guidelines for years) who were treated with MPH and ATX, respec-
children with ADHD using their e-textbook.61 Addi- tively, using a national database for post-marketing
tionally, the Texas Childrens Medication Algorithm phase IV pharmacovigilance. Of all the children, 7%
Project of ADHD, Canadian ADHD Practice Guide- were switched from MPH to ATX and 18% from
line and National Institute for Health and Clinical ATX to MPH. With regard to comorbidity control,
Excellence (NICE) guideline also provide treatment children treated with ATX had more adverse events
guidelines, including pharmacotherapy, for than those on MPH. These adverse events included
ADHD.106108 These guidelines, along with decreased appetite, weight loss, abdominal pain,
Taylor,109 indicate that medication is usually dyspepsia, stomachache, irritability, mood disorder,
attempted after psychological treatment and other dizziness, and gastrointestinal, neuropsychiatric, and
behavioral approaches, such as parent training and cardiovascular problems.
individual psychotherapy. ADHD symptoms usually have an impact through-
The guidelines of pharmacotherapy showed that out the day on both activities and relationships.
stimulants should be chosen as the rst medication There is a need for treatment approaches that take
and non-stimulants are chosen second if the stimu- into account the 24-h impact of the disorder and
lants are ineffective or if side-effects are very include all-day coverage with effective medication.
severe.110 On the other hand, previous studies have In contrast, pharmacotherapy often results in
shown the effectiveness of both stimulants and non- higher health-care costs (visits to the hospital for
stimulants in children with ADHD.111 The NICE physical examinations and prescription costs),
guideline indicates that the rst line of treatment for increasing the family economic burden.93
schoolchildren and adolescents with severe deterio- The treatments for children with ADHD and ASD
ration is methylphenidate (MPH; maximum dose raise clinical issues. Stimulants or non-stimulants
90 mg/day), atomoxetine (ATX; maximum dose can also be used to treat ADHD symptoms in chil-
80 mg/day) and dextroamphetamines (maximum dren with ASD/PDD.44,118122 They may have posi-
dose 20 mg/day).112 tive effects on social behaviors and self-regulation in
Results from a European survey of children with children with PDD and hyperactivity, as reported in
ADHD showed that 62% of children with ADHD the study of the National Institutes of Mental
were not currently receiving medication, 15% were Healths Autism Research Unit on Pediatric Psycho-
receiving 68 h of stimulant medication, and 23% pharmacology.123 Children may be vulnerable to
were receiving 12 h of stimulant medication. Chil- some MPH side-effects of exacerbated overactivity,
dren with ADHD receiving 12 h of stimulant medica- loss of appetite, stereotypical behavior, irritability,
tion experienced fewer challenges during the early and self-injury.121,124 In contrast, ATX is widely used
afternoon and late afternoon/early evening than chil- to treat ADHD symptoms in children with ASD/
dren receiving 68 h of stimulant medication. A total PDD,121 although their ADHD symptoms might not
of 68% of parents were satised with their childs respond to ATX treatment.125 Therefore, moderate
MPH and ATX doses for children with ASD should issue for which there is little information on the
be used.126 Mood dysregulation is also common in treatment and family burden.50
autism; indeed, in the USA, drugs such as risperi- CATTS was used to examine treatment effectiveness
done and aripiprazole have been licensed for the for 223 children with ADHD.53 The parents of chil-
treatment of irritability due to autism.81 dren with multiple comorbid conditions experienced
The quality of life improves with effective treat- the highest levels of depression, stress, and burden of
ment as family stress, parenting practices, caregiver care. Caregivers distress should be addressed in devel-
health, family relationships, and family processes oping treatment models for children with ADHD.53
related to ADHD management improve.127 ADHD Stringaris et al. reviewed that the parents of chil-
often induces chronic disorders in a childs life.29,128 dren with and without a dysregulated mood made
Changes in the conditions of children with ADHD similar changes to their parenting following the
and various comorbid disorders occur over time.29 intervention from a parenting intervention trial for
The presence of comorbid conditions or psychoso- antisocial children.69
cial stressors is related to the quality of life. The
MTA study showed a high degree of comorbidity
among youth with ADHD. The treatment strategy CLINICAL IMPLICATIONS
for these patients should be changed because of In the clinical eld, a child psychiatrist usually eval-
their comorbid disorders,24 and this is a new clinical uates the developmental condition of children with
Figure 2. Developmental condition and family burden of attention-decit hyperactivity disorder (ADHD). CD, conduct disor-
der; DMDD, disruptive mood dysregulation disorder; ODD, oppositional deant disorder.
ADHD. Many epidemiological, biological, and disorders might change over time, and the problems
follow-up studies support that the developing con- of children with ADHD will also change according
dition of ADHD is comprehensively understood as to their academic achievements and employment
demonstrated by biological dysfunctions, core problems. There is one proviso, DMDD is a new
symptoms, psychological problems, behavioral pro- clinical disorder, and it is unclear whether it is a
blems, and the environmental condition (Fig. 2). common comorbid disorder of ADHD. Evaluation
Sometimes, clinicians are faced with difculties in and treatment of children with ADHD and DMDD,
diagnosis when ADHD is comorbid with other psy- and discussions that focus on the differences
chiatric disorders and when it is necessary to distin- between DMDD and pediatric BD are insufcient.
guish between the diagnoses of ADHD with or However, irritability is a key symptom that clinicians
without DMDD/SMD, and pediatric or adult BD. It and researchers have used to evaluate the develop-
is a very important clinical issue to take a family his- mental condition of children with ADHD.
tory of ADHD, DMDD, BD, and other neurodeve- The second clinical issue is the family burden of
lopmental disorders into account, and to evaluate children with ADHD. This issue includes the treat-
the age of onset of the childs hyperactivity, impul- ment of children with ADHD in cooperation with
siveness, inattention, irritability, appetite loss, and their families according to changing clinical condi-
sleep disturbances to diagnose and properly treat tions. ADHD is sometimes a chronic disorder that
the condition. occurs over a long period, increasing the family bur-
Strong relationships between parents and clini- den of these children. The family burden will
cians might reduce the family burden during treat- increase with aging for unremitted children
ment of the child. For clinicians, evaluations during with ADHD.
different periods of the day are important as it Comorbid disorders of ADHD are related to qual-
allows them to characterize the childs daily life ity of life; the family burden of these children
through their relationships with their friends and includes academic achievements, trafc accidents,
parents.9,29,31,34 The clinician should prescribe cost- employment problems, and health-care costs.
effectively94 and target high-risk children after care- Clinicians should not only evaluate the mental
ful consideration has been given to the costbenet condition of the children but also evaluate the fam-
trade-off of early intervention strategies. It is also of ily burden. Children with ADHD should be treated
special clinical importance to evaluate children with in childhood to reduce their clinical symptoms and
ADHD at different times of the day because of the family burden.
differential acting duration between long- and short-
acting stimulants/non-stimulants.
Any depressive mood, anxiety, tic, or disruptive DISCLOSURE STATEMENT
behaviors of children with ADHD should be evalu- The authors have no conict of interest to report
ated and a treatment strategy should be decided regarding this review.
upon. However, DMDD has a new diagnostic crite-
rion in pediatric and adolescent psychiatry. Irritabil-
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