Marshall is a 6-year-old child who displayed significant symptoms of hyperactivity, impulsivity, defiance, and temper tantrums since 2 years of age. Marshall lives with his mother, a single parent, and two siblings, ages 4 and 1. His problematic behavior, defiance, and argumentativeness were significant problems at home for his mother, which often made her late to work in the morning. These behaviors were also problematic in the evenings at dinnertime and at bedtime not only for his mother but also for the whole family. Marshall was also having social problems at school including being increasingly shunned by other children because of his aggressiveness and impulsivity as well as being defiant and argumentative with his teachers.

His mother initially sought out her pediatrician, who indicated that Marshall was too young for medication and that better discipline techniques were necessary. Medical workup at that point was unrevealing of any significant condition responsible for Marshall's behavior. Marshall's mother continued to pursue a psychiatric evaluation for Marshall, and a formal psychiatric evaluation revealed diagnoses of attention-deficit/hyperactivity disorder (ADHD), combined type, and oppositional defiant disorder (ODD). Paper and pencil instruments were used including the Swanson, Nolan, and Pelham (SNAP) form for assessing ADHD and ODD symptoms. On the form, both Marshall's mother and teacher indicated that he was significantly elevated in both ADHD and ODD symptom domains, and target symptoms were identified: hyperactivity, impulsivity, short attention span, difficulty with follow through, defiance, argumentativeness, tantrums, and the beginnings of aggressiveness.

The presentation of attention-deficit/hyperactivity disorder (ADHD) in adolescence is often complex, but clinicians will attest multiple and complex comorbid conditions in adolescence are by no means unusual. Given that this is often the typical presentation, this article will describe a case to illustrate the multiple pathways to treatment of an adolescent with myriad distinct but interacting issues. Although all clinicians attempt to practice evidence-based medicine, the evidence is often limited to circumscribed disorders, and management and sequencing of treatment of adolescents with a combination of different conditions has not be adequately researched.

The National Comorbidity Survey Replication by Kessler and colleagues found that of adult patients with major depressive disorder (MDD), 9.4% met Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised criteria for attention-deficit/hyperactivity disorder (ADHD). Among those with dysthymia, 22.6% also met criteria for ADHD. In addition, it is estimated that approximately a third of the United States population experiences MDD symptoms at any point in time. Kessler and colleagues also conducted a retrospective study on impairment of adults with ADHD and found that ADHD has a prevalence of ∼4.4% in the US adult population, which suggests that ∼9 million US adults may have ADHD.