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Associated Symptoms of Attention-Deficit/Hyperactivity Disorder and Posttraumatic Stress Disorder

Karen Dineen Wagner, MD, PhD

Published: May 15, 2012

Associated Symptoms of Attention-Deficit/Hyperactivity Disorder and Posttraumatic Stress Disorder

This section of Focus on Childhood and Adolescent Mental Health includes articles about associated symptoms of attention-deficit/hyperactivity disorder (ADHD) and posttraumatic stress disorder (PTSD) that may warrant clinical evaluation and treatment in children and adolescents.

The core symptoms of ADHD are inattention, hyperactivity, and impulsivity. Connor and Ford examined emotional and behavioral symptoms that may be associated with ADHD in children and adolescents. The study included 175 clinically referred children and adolescents with ADHD combined subtype (inattention and hyperactivity-impulsivity) and 70 children and adolescents with ADHD inattentive subtype. The control groups consisted of 65 youth with non-ADHD psychiatric disorders (affective and anxiety disorders) and 72 community youth with no psychiatric disorders. The ages of the study participants ranged from 3 to 19 years, with a mean of 9 years for the ADHD combined group and 12 years for the ADHD inattentive group. A structured diagnostic interview and parent, teacher, and child rating scales were administered to the participants to assess diagnoses, internalizing and externalizing disorders, depression, overt aggression, proactive and reactive aggression, hostility, functional impairment, and global symptom severity.

Both groups with ADHD had comparable internalizing symptoms (affective and anxiety symptoms) as those of the non-ADHD psychiatric control group. Children and adolescents with ADHD combined subtype had higher externalizing behavior symptoms and higher aggression scores than the other groups. Youth in the ADHD combined subtype group were more severely impaired than any of the other groups. The youth with ADHD combined subtype also had higher scores on proactive aggression (unprovoked aggression) than any of the other groups. Interestingly, as ADHD symptom severity increased, emotional and behavioral symptoms also increased. The authors recommend that internalizing symptoms, externalizing behaviors, and aggression be assessed in the evaluation of children with a diagnosis of ADHD. Treatment for these associated symptoms may be necessary in addition to treatment for the core symptoms of ADHD.

Kim and colleagues1 previously reported a 6-month follow-up of Korean elementary school children who witnessed 2 mothers of the school children die during a fire escape drill after falling from a basket that snapped from a fire engine ladder. At 6-month follow-up, 5.2% of the children who directly witnessed the event had a diagnosis of PTSD, as well as other anxiety disorders. In this issue, we feature a study exclusively online at PSYCHIATRIST.COM by Song and colleagues, who conducted a 30-month prospective follow-up of 167 of these children who directly witnessed the deaths at school to determine any changes in PTSD symptoms and their quality of life. The mean age of the children was 12 years. The time points for the assessments following the witnessing of the deaths were 2 to 7 days, 2 months, 6 months, and 30 months. Psychiatric diagnoses were determined by a semistructured diagnostic interview. Parent and child rating scales that assessed anxiety and depression symptoms as well as parental rearing stress were included in the assessments.

Over the course of this 3-year period, the prevalence of anxiety and severe PTSD decreased. However, depressive symptoms did not significantly decrease over time. Depressive symptoms in the children were associated with lower quality of life for the children and higher parental rearing stress. These findings support the persistence of depressive but not PTSD or anxiety symptoms in children who witness a single traumatic event. The authors recommend that clinicians assess depressive symptoms in children who have been exposed to a single traumatic event because treatment for depression may be warranted.

The authors of the articles included in this month’s Focus on Childhood and Adolescent Mental Health section have shown the importance of examining additional symptomatology that may be associated with psychiatric disorders in children and adolescents.


1. Kim BN, Kim JW, Kim HW, et al. A 6-month follow-up study of posttraumatic stress and anxiety/depressive symptoms in Korean children after direct or indirect exposure to a single incident of trauma. J Clin Psychiatry. 2009;70(8):1148-1154. PubMed doi:10.4088/JCP.08m04896

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