Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults

Several recent comprehensive books dealing with the understanding, evaluation, and treatment of attention-deficit hyperactivity disorder (ADHD) (1,2) have included large sections about the myriad comorbid conditions frequently seen in individuals with ADHD. Yet the coming of age of a clinical condition can be marked by the number of texts published about specific aspects of the disorder. This book, edited by Thomas Brown, Ph.D., is the second of its kind in as many years devoted exclusively to the understanding, evaluation, and treatment of persons with ADHD who present with comorbid conditions.

Unlike its excellent predecessor by Pliszka and his associates (3), this text has a far more ambitious breadth and scope, including coverage of individuals throughout the life span as well as offering extended discussions of conditions beyond typical comorbidities such as sleep, coordination, and substance use disorders. The contributors form a who's-who of respected clinicians and researchers in the field of ADHD. The chapters are thorough, well written, and integrated, unlike material often encountered in edited volumes.

To make effective use of this text, however, readers must possess a thorough understanding of ADHD as a clinical condition. To that end, the editor offers a beginning chapter dealing with "the emerging understandings of attention-deficit disorders and comorbidities." Unfortunately, the chapter falls far short of a thorough, scientific review of the literature that would give readers a firm foundation for understanding the vulnerability of those with ADHD to comorbid conditions. Instead, it presents a rather unidimensional view of the editor's beliefs about the field of ADHD, including his perception that attention problems are central to ADHD. In fact, Dr. Brown goes so far as to state that "the title of this book uses the term attention-deficit disorder to emphasize the centrality of attention impairments, with or without hyperactivity, in the disorder."

The chapter also contains a questionable interpretation of the epidemiologic data. In particular, Dr. Brown argues that not only are attentional problems central to ADHD but that persons with the inattentive subtype of the condition may be underdiagnosed. Scant attention is paid to the role of faulty activation, inhibition, self-regulation, and impulsive behavior in this condition; this chapter also does not consider the role of hyperactive-impulsive symptoms, even though a more robust literature supports this underlying etiology (4,5).

Although the good work of Dr. Joseph Biederman and the Harvard group (6) is mentioned in this chapter, the recent research of this group and others suggesting that ADHD represents a unitary condition falling along a continuum of severity is not noted. Dr. Brown's theory on the central role of attention in ADHD is not supported in this chapter, nor does the chapter set a firm foundation explaining the dramatic risk of comorbidity in patients with ADHD. That phenomenon is in fact better explained when problems with inhibitory and activation processes are examined.

Fortunately, the contributors to the text stick with accepted clinical and scientific terminology and do not set out to redefine ADHD on the basis of personal ideology. The contributors, including Dr. Brown in the number of chapters he authors or coauthors, get on with the business of reviewing the available scientific literature, offering strategies, suggestions, and ideas for assessment and effective treatment for individuals with ADHD and comorbid conditions. Researchers and clinicians with a focus on ADHD should consider this volume a valuable desk reference.

Dr. Goldstein is with the Neurology Learning and Behavior Center and the University of Utah in Salt Lake City.