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How do you decide what to treat first when there is more than one diagnosis?

What Causes the Most Trouble is Diagnosed First
It’s often not ADHD…

The condition that causes the most trouble or distress is the first to be identified and treated, followed by the underlying ADHD. Dr. Thomas E. Brown tells us why this is the often the situation.

Transcription follows 4:59 minute video

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Lightly Edited Transcript

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What gets diagnosed first is what’s most obvious, what’s making the most trouble for the person at the time. And if you’ve got somebody who’s being brought in because they’re terribly depressed – they’re eating and sleeping or such that either sleeping all the time and not have difficulty being awake or that they can’t sleep very well and so, as a result, they don’t get much sleep.

Or it may be that there’s a problem where they’re having panic attacks – you know acute anxiety episodes where they’re just feeling so nervous that everything is bothering them.

These are things that you have to think about. Or it may be a kid who’s struggling in school and has great difficulty in being able to organize his or her thoughts and put them into sentences and paragraphs.

So you ask about what’s the presenting problem? Why is it that this particular parent has brought their child – their son or daughter – in to get evaluated or why is it that this adult is coming in?

And sometimes the presenting problem is not ADHD. The presenting problem may be the anxiety or it may be that they’re feeling profoundly depressed or it may be that they are smoking way too much weed or drinking way too much and it’s making a lot of trouble.

And then, oh by the way, it turns out they’ve got ADHD. Or sometimes they’ll come in to talk about the ADHD and then if they begin to trust the interviewer – the clinician who’s working with them – they begin to talk about some other things that may be a little more embarrassing for them.

So, I think it’s not like it’s always one thing. Sometimes the ADHD is the presenting problem. I’m having a lot of trouble focusing. I read and I don’t remember what I’ve just read. I turned the page and I seem to have lost what I was reading just a moment ago and so I’ve got to go back and read the damn thing again.

Sometimes it’s a matter of a person not talking about the ADHD thing, but just mainly talking about how they’re having these panic attacks where it feels like they need to go to the hospital for, you know, because they’re getting shortness of breath.

It feels like their heart is going to jump out of their chest and they get panicky. It may only last for 15 minutes or so, but it’s enough to be terrifying. You know and so the clinician needs to listen to what the person’s presenting problem is and consider it in its own terms and then also think about the possibility of could it be, are there other things the person is saying which make it appear that perhaps there’s ADHD involved as well?

And when you’re talking, for example, about adults, the research which has been done on adults 18 up to 44-50 years old. A person with ADHD has six times the likelihood of having at least one other psychiatric disorder on top of it.

And so it’s very important to look for these other things and see what’s making the trouble and then what’s the most effective way of dealing with it. And sometimes it’s straightforward ADHD.

Far more common whether you’re talking with children or with adults, there’s something else in the package. And it may be that the ADHD is the main thing that people are thinking about talking about and complaining about.

Or it may be that one of these other disorders is making a lot of trouble for them and that in the course of evaluating for that you can see, yes, ADD is an underlying feature which has not really been mentioned.

About the Speaker

Thomas e brown

Thomas E. Brown earned his PhD in Clinical Psychology at Yale University and served on the Yale faculty for 25 years. He is now Director of the Brown Clinic for Attention and Related Disorders in Manhattan Beach, CA, is an elected Fellow of the American Psychological Association, and has published numerous articles and six books on ADHD. His website is

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