Download Pediatric Mental Health Update-Grewe

Pediatric Mental Health Update
Scott Grewe, Ph.D., ABPP/CN
Sageview Youth Psychology
1950 – O Keene Road
Richland, WA
www.sageviewpsych.com
Objectives for Presentation
Overview the most common mental health disorders in children and adolescents (ADHD,
anxiety disorders, & depression).
Develop an understanding of how these disorders adversely affect behavior, social
involvement, and learning, with regard to the framework of the gas, brake, & clutch.
Overview evidence-based psychotherapeutic interventions commonly used in treating these
disorders.
Overview evidence-based accommodations commonly used in the home and school
environments to support children and adolescents with these disorders.
Share observations and clinical insights from two decades of practice, and highlight relevant
protective factors across developmental stages.
Briefly describe a few community organizations that address these issues.
ADHD: The gas & brake
Inattentive symptoms – Reflect poor sustained attention, failure to attend to details,
poor follow through, difficulties organizing, forgetfulness, & avoidance of effortful
tasks; think difficulties because of Errors of Omission…
Hyperactive-Impulsive symptoms – reflect disinhibition and behavioral dysregulation;
think difficulties because of Errors of Commission…
Core executive function deficits – poor planning, problem solving, time management,
working memory, cognitive flexibility, task initiation and completion, etc.
Levels have to be developmentally inappropriate, persist for >6 months, occur across
settings, interfere with life, onset before age 12, and not occur exclusively in the
context of ID, ASD, or Psychosis; developmental vs. acquired…
The rest of the diagnostic story…
1.
Inattentive & Hyperactive-Impulsive symptoms reflect different functional
difficulties and probably different disorders
2.
Qualitatively no difference between the hyperactive-impulsive and
combined types. Probably more an index of severity and age at diagnosis.
3.
Symptoms are not developmentally scaled, cut-offs are not
developmentally or gender referenced, time frames are inappropriate, and
parent-teacher agreement is problematic
4.
The context influences the expression of underlying difficulties
ADHD, Predominantly Inattentive
Type
1. 30-50% of Inattentive Type are Sluggish Cognitive Tempo (SCT); daydreaming &
spaciness, slow information processing (CAPD?), hypoactive & lethargic, easily
confused & mentally “foggy”
2. Beware the pseudo-inattentive type - the 50-70% who aren’t SCT: Combined type
that changes by adolescence or adulthood (think combined type), cases that are
subthreshold combined type, adult onset (think alternative diagnosis)…
3. Differential Dx: focus on sluggishness & passivity…
Related cognitive deficits…
1. Slow & variable reaction time
2. Impulsivity & missed signals
3. Distractibility
4. Reduced sensitivity to errors
5. Poor mental computation and memory for verbal sequences
6. Poor spatial memory
7. Delayed internalization of speech
8. Poor time reproduction
9. Concrete & disorganized story recall
The social consequences…
Increased parent-child conflict & stress, especially the ODD/CD subgroup
Peer relationship problems (50+%)
Less sharing, cooperation, & turn taking
More talking, commanding, & intrusion
Most serious in ODD/CD subgroups
Poor emotional control
More anger, frustration, & hostility (ODD/CD)
Less self-regulation of emotional state (poor emotional regulation + increased
aggression = social rejection!)
ADHD as a gateway…
First described by Melchior Adam Weikard in 1775, medical description by Benjamin Rush
over 200 years ago, over 75 years since amphetamine-like drugs found helpful…
S ool
School failure;
ch
underachievement
Low birth weight;
poor maternal
nutrition, pesticide
exposures, maternal
stress; extreme
family conflict
Un- or under
employment
Child ADHD;
Gateway
Drug use;
delinquency
Depression;
suicide attempts
Genotype; gene
expression;
temperament; social
supports
Serious accidents;
injuries; bad driving
Marital problems,
conflicts, divorce
From Nigg & Barkley (2014). Attention Deficit/Hyperactivity Disorder, in Child Psychopathology,
3rd Edition. Eric Mash & Russell Barkley (eds.)
Obesity; poor
fitness
Where does it go?
As assessed by DSM-based structured interviews
Symptoms decrease – from average of 9 at age 15 to average of 7 at age 21
Adolescence – 70-80% persistence (based on parent reports)
Young adulthood (age 20-26) – 3-8% have full disorder (self-report), 46% have full
disorder (parent report); 12% using 98th percentile or +2 SDs (self-report), 66% using
98th percentile (parent report)
Parent report correlates more highly with various domains of major life activity than
does self-report!
Where else does it go?
Psychiatric disorders – increased incidence of ODD, CD, depression, substance
use/abuse, & personality disorders
Educational outcome – more grade retention, more suspensions & expulsions, higher
drop-out rate (250-300K cost to society), lower class ranking & GPA, & less likely to
attend &/or complete college
Employment outcome – more likely to be fired, more job changes, more ADHD/ODD
symptoms on the job, lower work performance ratings, lower SES, & 35% selfemployed by their 30’s
There’s more?
Motor vehicle risks – poorer steering, false braking, & slower reaction times, fewer safe
driving habits, more likely to drive before licensing, more accidents (& more at fault), more
citations (speeding 4-5 vs. 1-2), worse accidents ($4200-5000 vs. $1600-2200; crash
w/injuries, 60 vs. 17%), & more suspensions (22-24 vs. 4-5%) and revocations (average of
2.2 vs. .7)
Sexual-reproductive risks – earlier initiation of sexual activity, more sexual partners, higher
risk of STDs (16 vs. 4%), less use of contraception, & greater incidence of teen pregnancy
(38 vs. 4%) & births (ratio of 42:1; 54% do not have custody)
The clinical perspective I share with families is that youth with ADHD “blow through the
intersections” of life because they struggle to get off the gas and tap the brake. Do thisdon’t do this, say this-don’t say this, feel this-don’t feel this, etc. They also tend to have a
hard time learning from experience…
“A chill in the Air,” by James Carroll, The Boston Globe
Magazine (September 1, 1996, pp. 16-21); in ADHD and
the nature of self-control, Barkley, 1997
Over the years, the turning of the seasons has become an irrefutable image of
the life cycle itself. Your youth is precious to me, in part as compensation for
the loss of my own…The end of summer lays bare the law of time. My life ends,
and so will yours. Time itself will end...Young as you are, you know this…At a
certain point you had accumulated enough past to imagine a future. The arc of
experience revealed itself to you. This was the beginning of the end of your
childhood, when looking backward forced you to look ahead. Before that, the
lack of a larger frame within which to interpret occurrences left you at the mercy
of a dislocated present, a condition of absolute immediacy. Young children take
such a state for granted. We call it pure innocence. What you were innocent of
was time…The awareness of mortality, and only that, enables us to see fully
our real place in the universe, and the name for our place is time. Once we see
this, everything changes. The sadness in the death of the living things does not
go away, but it takes on a silent and equal partner, which is the feeling of
acceptance. That is the definition of happiness-when we mortal beings accept
ourselves as such. The two-dollar word for this change is “transcendence,” and
what we have transcended, in accepting time, is time itself.
Anxiety Disorders – The brake &
clutch
Fear is the “fight or flight” response and activates the autonomic nervous system
Anxiety is a mood state characterized by negative affect. Some anxiety is adaptive and assists
us. Trait vs. state…
Fear vs. Anxiety? Is the threat immediate or delayed & Is the reaction alarm or an elevation of
tension. Both have three components (cognitive, motoric/behavioral, & physiological)
Worry is the cognitive component of anxiety. It helps & hinders…
Developmental Phenomenology of
Childhood Fears & Worries
0-6 months: loud noises, loss of support, excessive sensory stimuli
6-9 months: strangers, novel stimuli (masks), heights, sudden or unexpected stimuli (noise,
bright lights, etc.)
1 year: separation from caretakers, strangers, toilets
2 years: auditory stimuli (trains, thunder, etc.), imaginary creatures, darkness, separation from
caretakers
3 years: visual stimuli (masks), animals, darkness, being alone, separation from caretakers
4 years: auditory stimuli, darkness, animals, parents leaving at night, imaginary creatures,
burglars, separation from caretakers
Developmental Phenomenology of
Childhood Fears & Worries, II
5 years: visual stimuli, concrete stimuli (injury, falling, etc.), “bad” people, separation from
caretakers, imaginary creatures, animals, harm to self or others
6 years: auditory stimuli, imaginary creatures, burglars, sleeping alone, harm to self or others,
natural disasters, animals, dying or death of others
7-8 years: imaginary creatures, staying alone, harm to self or others, exposure to
extraordinary events (bombings, kidnappings, etc.), failure & criticism, medical/dental
procedures, dying or death of others, frightening dreams or movies, animals
9-12: failure & criticism (e.g., school evaluation), rejection, peer bullying or teasing,
kidnapping, dying or death of others, harm to self or others, illness
Anxiety Disorders in Childhood &
Adolescence
Separation Anxiety Disorder – Difficulty leaving their parents to attend school, staying at a
friend's house, or being alone. Often "clingy" and have trouble falling asleep. Separation
anxiety disorder may be accompanied by depression, sadness, withdrawal, or fear of harm
to a family member.
Generalized Anxiety Disorder – Extreme, unrealistic worry about everyday life activities.
Worry unduly about academic performance, sporting activities, or even about being on
time. Typically very self-conscious, tense, and have a strong need for reassurance. May
complain about stomachaches or other discomforts that do not appear to have any
physical cause.
Panic Disorder - Repeated instances of intense fear accompanied by a pounding heartbeat,
sweating, dizziness, nausea, or a feeling of imminent death. The experience is so scary
that young people live in dread of another attack. Children and adolescents with the
disorder may go to great lengths to avoid situations that may bring on a panic attack.
Anxiety Disorders in Childhood &
Adolescence, II
Social Phobia – Most common anxiety disorder in kids. Strong, irrational fear about
social performance.
School Refusal – Avoidance, escape, attention seeking, tangible reinforcement.
Obsessive-Compulsive Disorder – Children and adolescents with OCD become
trapped in a pattern of repetitive thoughts and behaviors. Even though they may
recognize that the thoughts or behaviors appear senseless and distressing, the
pattern is very hard to stop. Compulsive behaviors may include repeated hand
washing, counting, or arranging and rearranging objects. About two in every 100
adolescents experience obsessive-compulsive disorder
Post-Traumatic Stress Disorder – Children and adolescents can develop posttraumatic stress disorder after they experience a very stressful event, such as
physical or sexual abuse, being a victim of or witnessing violence, or living through a
disaster. Young people with post-traumatic stress disorder re-experience the event
through strong memories, flashbacks, or other kinds of troublesome thoughts. As a
result, they may try to avoid anything associated with the trauma. They also may
overreact when startled or have difficulty sleeping.
Epidemiology of Trauma
1.
7 of 10 will experience an extraordinary event (tragic death, natural catastrophe, assault,
etc.) during lifetime. 20% of those individuals will become “traumatized.”
2.
Witnessing violence between parents or caretakers is the strongest risk factor for
transmitting violent behavior from one generation to the next.
3.
Boys who witness domestic violence are, as adults, twice as likely to abuse their partners
and children.
4.
30-60% of perpetrators of intimate partner violence also abuse children in the household.
5.
A fraction who experience an extraordinary event become “traumatized.” Less is known
about what protects children from developing symptoms or places them at risk, although
level of exposure, type, & duration of trauma, pre-existing psychopathology, impact on the
social structure, biological factors, and subjective experience are correlated with risk.
Comorbidity, or what goes with it…
Anxiety disorders are among the most common mental, emotional, and behavioral problems in
childhood and adolescence (13 of every 100 children and adolescents ages 9 to 17
experience some kind of anxiety disorder & girls are affected more than boys)
Co-occurrence with other Anxiety disorders in lifetime is 65-95%
Anxiety and depression share “negative affect” but high arousal is specific to anxiety
Co-occurrence with ADHD increases with age from 20-50%. Anxiety seems to serve as the
“brake” for ADHD…
The clinical perspective I share with families is that youth with anxiety disorders “ride the
brake” through life, or at least in settings where their anxiety impedes their adaptive
functioning. They also tend to have difficulties “pushing in the clutch and shifting gears,”
which often presents as rigidity. Lastly, if untreated, their anxiety often causes their
“universe” to shrink…
Depressive Disorders: Staying
steady on the gas…
Depressive Disorders – Mean onset around 11 for Dysthymic Disorder & 14 for Major
Depressive Disorder. Age of onset is important as younger children have heterotypic vs.
adolescent homotypic continuity.
Childhood onset of unipolar depression is relatively rare. Most have a history of dysthymia, and
anxiety is also quite common precursor. Cyclothymia is quite difficult to distinguish.
Bipolar Disorder – At its most basic, represents dysregulation of mood and energy. Mood
disturbance is emphasized in the DSM-5 but changes in energy and somatic aspects of
the disorder are likely at least as important.
Bipolar I – Requires at least one lifetime manic episode, and this is the defining
characteristic.
Bipolar II – Best considered a form of depressive illness, although requirement for a
hypomania episode.
Disruptive Mood Regulation Disorder – The absence of prevalence data, longitudinal course,
treatment response, and diagnostic specificity make it problematic.
How do they struggle?
Peer relationships are often disrupted because of excessive needs for reassurance,
ineffective responses to social stressors, rejection, exclusion, and victimization.
Leads to a cycle of increasingly low social status.
Appetitive behaviors (sleeping & eating) are some of the first indicators of struggle. Too
much/little sleep, weight loss/gain.
Concentration, organization, and follow-through are common academic struggles.
Additionally, initiation and motivation deficits in the depressed child/adolescent
are paramount. The clinical perspective I share with families is that they
struggle to “stay on the gas” in their lives. This results in inconsistent behavior,
emotion, academic performance, and adaptive functioning.
Etiology of Depression…
Biological
Vulnerabilities
Early Adverse
Experiences
Emotional
Vulnerabilities
Proximal
Stressors
Genetic
Characteristics
DEPRESSION
Cognitive
Vulnerabilities
Interpersonal
Vulnerabilities
From Hammen, Rudolph, & Abaied (2014). Child and adolescent depression, in Child Psychopathology,
3rd Edition. Eric Mash & Russell Barkley (eds.)
Insights from two decades of
clinical practice…
Comorbidity is the rule, not the exception!
ADHD as a prototypic example:
Externalizing Disorders
Oppositional Defiant Disorder (40-67%)
Conduct Disorder (20-56%)
Delinquent/Antisocial Activities (18-30%)
Internalizing Disorders
Anxiety Disorders (10-40%)
Major Depression (0-45%; 27% by age 20)
Bipolar Disorder (0-27%; likely 6-10%)
More insights…
Developmental “stress points” – Start of school, academic transition from acquisition to
application around 3rd grade, middle school, high school, college) often
exacerbate underlying vulnerabilities, causing onset or re-emergence of
difficulties. Not surprisingly, these are common times for referral to mental
health professionals.
Multigenerational Transmission of Symptoms – Speaks to the contribution of genetic
influences and the environment to who and how we are. It is nature and
nurture, and families tend to recreate what they know…
When does treatment work? Most effective when all parties are on board. Children and
adolescents do not live in a vacuum. Involving the family and other involved
adults in treatment is often the critical factor in successful outcomes.
Executive function deficits are often overlooked and under addressed. Unfortunately, they
account for a significant amount of the academic morbidity.
So what can we do?
Interventions w/Parents – Family-focused interventions for preschool and early elementary
age children, and parent/teen for adolescents. Helps parents change the environment,
interact more positively with their child, use positive reinforcement, and use positive
approaches to discipline. Efficacy is high in childhood (80-85% of families report positive
outcomes) but drops dramatically when youth reach adolescence (biology, peer group, &
unique events).
Cognitive Behavioral Therapy – Focuses on cognitive distortions, increasing pleasure, and
changing specific response patterns. Particularly effective for >9 year olds. Outcome
studies show these approaches to be more effective long-term than medication
interventions, likely because of the skill-building nature of the intervention.
Intervention in the Environment – Temporarily reduce demands, provide additional support
and encouragement, encourage use of coping skills, and help the child to think positively.
Supports in the major performance setting help boost self-esteem and self-concept, and
help keep “doors open” for future academic and vocational options.
Academic Intervention &/or
Accommodation
School is the primary “workplace” & social setting for children & teens. Success/failure in a
major life endeavor is critical.
Special Education (IDEA) or Regular Education accommodations (Section 504)? Answer 3
questions…
Regular Education accommodations are quickly implemented and often very helpful in
reducing demands.
Special Education is more difficult to implement but often times necessary to address related
cognitive and learning struggles.
There has be more, right?
Consider that developmental transitions are associated with some degree of “stress.”
Developmental “stress points” (start of school, academic transition from acquisition to
application around 3rd grade, middle school, high school, college) often exacerbate
underlying vulnerabilities, causing onset or re-emergence of difficulties. Not
surprisingly, these are common times for referral to mental health professionals.
Inform your expectations with the understanding that children are (generally) striving to
adapt. 99+% of kids are doing the best they can with what they have…
Prudently pick the settings in which children function.
The greatest gifts we can give children who struggle, other than our love and attention, are
consistency, predictability, structure, and routine.
Protective Factors



Childhood – Secure attachment, ability to make friends; consistent discipline, safety,
responsive parents.
Middle School – Solid academic performance, ability to make friends, good peer
relationships; consistent discipline, extended family support; health peer group,
school engagement, positive teacher expectations, reduced bullying, positive
partnering between parents and school.
High School – Positive physical development, emotional self-regulation & good selfesteem, engaged in school activities, employment, religion, or culture;
structure, limits, rules, & expectations at home for behavior, consistent values,
supportive relationships with family members; presence of mentors & support
for developing skills and interests, opportunities for engagement at school,
physical and psychological safety.
General Ideas for Management
Parents/Adults are Shepherds; not Engineers
Use immediate feedback
Increase accountability to others
Touch more, talk less
Act, don’t yak…
Keep your sense of humor
Use rewards before punishment (reward early & often!)
Anticipate problem settings; & make a plan for them!
Keep a sense of priorities (what’s really important…)
Practice forgiveness (child, self, others)
General Resources


Helping your anxious child; A step-by-step guide for parents: Second Edition (2008). R. M. Rapee, et.al. New
Harbinger Publications, Inc.
My anxious mind: A teen’s guide to managing anxiety and panic (2010). M. A. Tompkins & K. A. Martinez.
Magination Press, American Psychological Association: Washington, D.C.

Understanding myself: A kid's guide to intense emotions and strong feelings (2010). M. Lamia. Magination
Press, American Psychological Association: Washington, D.C.

Getting to calm: Cool-headed strategies for parenting tweens and teens (2009), J. Wyatt & L. Kastner.
Parent Map: Seattle, WA.

Negotiating parent-adolescent conflict: A behavioral family systems approach (2002). A. Robin & S. Foster.
Guilford Press: New York.

Smart but scattered teens: The “executive skills” program for helping teens reach their potential (2012). R. Guare,
P. Dawson, & C. Guare. Guilford Press: New York.
Community Resources



Catholic Family & Child Services: Family-based approach to mental health services for children, adults,
and families. Mostly Medicaid but a limited traditional insurance presence, and also offer a sliding
fee scale on a limited basis.
• CBT+: Parent Management Training (PMT), Parent-Child Interaction Training (P-CIT), Traumafocused therapy
• Pal+: Time-limited therapy for children with disruptive behavior and depressed teens.
• Telepsychiatry: Services provided in collaboration with Seattle Children’s Hospital through Lisa Chu,
ARNP.
• Susan Lind @ 545-4645
Lourdes Counseling Center: Children’s Day Program, Medication Management, Case Management,
Individual Therapy, Crisis Response Unit (CRU). Currently recruiting another child/adolescent
psychiatrist.
Lutheran Community Services Northwest (LCSNW): Wrap-around philosophy for all services provided
to youth with intensive mental health needs.
• SWIFT (Stabilization & Wellness in Families Together) – Crisis stabilization for youth in their natural
environment. Referrals typically through CRU…
• Crisis Stabilization Bed – Referred by anyone and serve as a short-term step-down or de-escalation
setting.
• Three Rivers Wrap-Around – Fidelity-based program that collaborates with community providers.
• Wrap-Around with Intensive Services (WISe) – Consequent to State of Washington being sued for
not providing appropriate care. Primary difference between WISe and Fidelity program is the
involvement of a mental health therapist through LCSNW.
• Only children insured through Medicaid can access the last two programs.
• Sharon Gentry @ 753-6446
Summary
The common psychiatric disorders in children and adolescents have core deficits that impede
adjustment in affected individuals. The gas, brake, & clutch is a helpful framework for
understanding deficits in behavioral, cognitive, and emotional dysregulation.
Comorbidity is the rule in clinical practice.
Developmental “stress points” exacerbate underlying vulnerabilities, and family issues tend to
be generational.
Therapeutic interventions work when implemented with fidelity.
Treatment works when everyone is on board!
Identifiable factors from childhood through adolescence serve as protective buffers.
Suggested Readings

Barkley, R. A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD.
Psychological Bulletin, 121(1), 65-94.

Barkley, R. A. (2013). Distinguishing sluggish cognitive tempo from ADHD in children and adolescents: Executive functioning,
impairment, and comorbidity. Journal of Clinical Child and Adolescent Psychology, 42, 161-173.

Blakemore, S. J. (2012). Sarah-Jayne Blakemore The mysterious workings of the adolescent brain. Retrieved from
http://www.ted.com/talks/sarah_jayne_blakemore_the_mysterious_workings_of_the_adolescent_brain

Bridging research and practice: Evidence-based behavioral-practice (www.ebbp.org/index.html).

Christopherson, E. R. & Mortweet, S. L. (2001). Treatments that work with children: Empirically supported strategies for managing
childhood problems. American Psychological Association: Washington, D. C.

Fonagy, P. Conttrell, D., Phillips, J., Bevington, D., Glaser, D., & Allison, E. (2015). What works for whom? A critical review of
treatments for children and adolescents. New York: The Guilford Press.

Grewe, S. D. & Yeates, K. O. (2012). Neuropsychological assessment and the neurologically impaired child. In clinical child psychiatry,
third edition. W. M. Klykylo & J. L. Kay, (eds.). Wiley and sons: New York.

Christenson, J. D., Crane, R. D., Malloy, J., & Parker, S. (2016). The cost of oppositional defiant disorder and disruptive behavior: A
review of the Literature. Journal of Family Studies, 25, 2649-2658.

Jackson Foster, L. J., Phillips, C. M., Yabes, J., Breslau, J. O’Brien, K., Miller, E. & Pecora, P. J. (2015). Childhood behavioral
disorders and trauma: Predictors of comorbid mental disorders among adult foster care alumni. Traumatology, 21, 119-127.

Klever, P. (2004). The multigenerational transmission of nuclear family processes and symptoms. The American Journal of Family
Therapy, 32(4), 337-351.

Musser, E., Karalunas, S. L., Dieckmann, N., Peris, T. S., Nigg, J. T. (2016). Attention-Deficit/Hyperactivity Disorder developmental
trajectories related to parental expressed emotion. Journal of Abnormal Psychology, 125, 182-195.
Additional readings…

O’Connell, M. E., Boat, T., & Warner, K. E. (2009). Preventing mental, emotional, and behavioral disorders among young people:
Progress and possibilities. Washington, DC: The National Academies Press and U.S. Department of Health and Human
Services, Substance Abuse and Mental Health Administration.

Pennington, B. F. (2014). Explaining abnormal behavior. New York: Guilford Press.

Pennington, B. F. (2002). The development of psychopathology: Nature and nurture. The Guilford Press. New York.

Pliszka, S. R. (2015). Comorbid psychiatric disorders in children with ADHD. In attention deficit hyperactivity disorder: A handbook for
diagnosis & treatment. The Guilford Press: New York.

Rapin, I. (2014). Classification of Behaviorally Defined Disorders: Biology Versus the DSM. Journal of autism and developmental
disorders, 44(10), 2661-2666.

Smith, T. (2005). The appeal of unvalidated treatments. In controversial therapies for developmental disabilities: Fad, fashion, and
science in professional practice. J. W. Jacobson, R. M. Foxx, & J. A. Mulick (eds.). Lawrence Erlbaum Associates: Mahwah,
New Jersey.

Society of Clinical Child & Adolescent Psychology, American Psychological Association; Effective child therapy: Evidence-based
mental health treatment for children and adolescents (www.effectivechildtherapy.org).

Steinberg, L. (2014). The age of opportunity: Lessons from the new science of adolescence. Houghton Mifflin Harcourt: New York.

Wakefield, J. C. (1997). Normal inability versus pathological disability: Why Ossorio’s definition of mental disorder is not sufficient.
Clinical Psychology: Science and Practice, 4, 249-258.

Willcutt, E. G. Nigg, J. T., Pennington, B. F., Solanto, M. V., Rohde, L. A., Tannock, R. (2012). Validity of DSM-IV attention
deficit/hyperactivity disorder symptoms, dimensions, and subtypes. Journal of Abnormal Psychology, 121 (4), 991-1010.

Willcutt, E. G., & Pennington, B. F. (2000). Psychiatric comorbidity in children and adolescents with reading disability. Journal of Child
Psychology and Psychiatry, 41(8), 1039-1048.