By Stephen R. Pliszka Guilford Press, 2009 Review by Benjamin J. Lovett, Ph.D. on Apr 13th 2010
It is difficult for formal coursework in clinical psychology to represent the challenges of actual clinical work, for many reasons. One reason is that different disorders frequently co-occur in clinical practice, and information that a student has learned about one disorder may not apply to a client who has an additional disorder as well. This problem of comorbidity (the existence of multiple disorders in the same individual) is especially prevalent in attention deficit hyperactivity disorder (ADHD); more than half of individuals who meet criteria for an ADHD diagnosis also meet the criteria for other psychological disorders.
In Treating ADHD and Comorbid Disorders, Steven Pliszka tackles the challenges posed by comorbidity head on. A psychiatrist who splits his time between research and clinical practice, Pliszka is in an ideal position to translate recent studies on ADHD treatment into useful guidelines for clinicians, and his book does not disappoint. The book is clearly written, well-organized, and a thoughtful integration of clinical wisdom and cutting-edge research.
Each chapter considers the relationship between ADHD and another disorder (or class of disorders): bipolar disorder, anxiety disorders, impulsive aggression, etc. Each chapter reviews the diagnostic criteria for potential comorbid conditions, summarizes research on the comorbidity relationships, and discusses treatment implications. While covering this information, Pliszka does not shy away from controversial issues. For instance, in the chapter on bipolar disorder, he opens by discussing the current "epidemic" of bipolar disorder among children, offering a balanced perspective. Although he seems a bit credulous regarding the high rates of pediatric bipolar diagnosis, Pliszka does consider alternative explanations of the reported prevalence rates, and he notes that many symptoms of mania could be explained as either severe ADHD or ADHD with comorbid conduct problems. Throughout the discussion of complex issues such as these, Pliszka does an excellent job of carefully and accessibly presenting research findings.
Multiple narrative case studies are also included in each chapter, to illustrate the concepts covered. These case studies demonstrate nicely the complexities of clinical work, highlighting the clinical issues raised by comorbidity. For instance, in one chapter, Pliszka discusses the case of 9-year-old Karen, who was already being treated for anxiety when her parents requested a second opinion about the medication that Karen was taking. The parents endorsed many symptoms of ADHD, and there were also signs of stubbornness and negativity that didn't quite fit with anxiety. Medication changes were of little benefit, whereas a behavior modification intervention worked surprisingly well. As is typical in the case studies, Pliszka places more emphasis on finding an effective way of meeting Karen's needs, rather than focusing on diagnosis per se. Although I had hoped for more information about diagnostic issues, many practicing clinicians will appreciate the book's pragmatic, treatment-focused approach.
Speaking of treatment, I should note that as the case study of Karen indicates, Pliszka does not have a bias favoring medication over psychotherapy. Even in his discussion of disorders closer to the "medical" end of the spectrum, Pliszka covers research-based psychological treatments. For instance, in the chapter on bipolar disorder, there is a fairly detailed account of the RAINBOW therapy system, which addresses a variety of psychosocial variables. Still, the discussions of medication management algorithms (which medications to try first, which next, etc.) will be most useful to those who have prescription privileges.
Overall, then, Treating ADHD and Comorbid Disorders is a helpful guide for practitioners who are looking for an accessible overview of research on ADHD comorbidity as well as down-to-earth advice about how to treat children who present with a variety of problems that include ADHD-related symptoms.