title: Impact of Mental Health Comorbidities on the Community-Based Pediatric Treatment and Outcomes of Children with Attention Deficit Hyperactivity Disorder.
abstract: Children with attention deficit hyperactivity disorder (ADHD) often exhibit psychiatric comorbidities, which may impact illness presentation, diagnosis, and treatment outcomes. Guidelines exist for dealing with these complex cases but little is known about how comorbidities are being handled in community pediatric settings. The purpose of this study was to evaluate how mental health comorbidities affect community physicians' ADHD care practices and patients' symptom trajectories.
  
  
  
  Medical charts of 319 children presenting at primary care clinics for ADHD-related concerns were reviewed. Physician assessment and treatment behaviors were extracted and parents rated ADHD symptoms at the time of diagnosis and at 3, 6, and 12 months. Baseline ratings were used to group children, as no comorbid mental health condition, internalizing, or externalizing comorbid condition. Multilevel analyses compared community physician care behaviors and ADHD symptom trajectories across groups.
  
  
  
  Approximately, 50 percent of the sample met screening criteria for a comorbid mental health condition. For children diagnosed with ADHD and treated with medication, community physician care largely did not differ across groups, but children with internalizing comorbidities made significantly smaller improvements in inattentive and hyperactive/impulsive symptoms compared with children with no comorbidities.
  
  
  
  Children with ADHD and mental health comorbidities, particularly internalizing disorders, exhibit less robust response to ADHD medication and may require additional testing before starting medication and/or alternative treatment approaches. Potential barriers to conducting comprehensive assessments and to providing multi-modal treatment are discussed.
authors.affiliation: *Department of Psychology, Virginia Commonwealth University, Richmond, VA; †Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario; ‡Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; §Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH; ‖The Children's Home of Cincinnati, Cincinnati, OH.
authors.forename: Nour
authors.initials: N
authors.lastname: Al Ghriwati
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Langberg
authors.forename: William
authors.initials: W
authors.lastname: Gardner
authors.forename: James
authors.initials: J
authors.lastname: Peugh
authors.forename: Kelly J
authors.initials: KJ
authors.lastname: Kelleher
authors.forename: Rebecca
authors.initials: R
authors.lastname: Baum
authors.forename: William B
authors.initials: WB
authors.lastname: Brinkman
authors.forename: Phil
authors.initials: P
authors.lastname: Lichtenstein
authors.forename: Jeffery N
authors.initials: JN
authors.lastname: Epstein
mesh_terms: D000328:Adult; D001289:Attention Deficit Disorder with Hyperactivity / Q000453:epidemiology / Q000628:therapy*; D002648:Child; D003153:Community Health Services / Q000706:statistics & numerical data*; D015897:Comorbidity; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*