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Dr. Antshel describes an interesting and relatively typical case of a young adult referral in which ADHD has been previously diagnosed. Pat’s history of repetitive antisocial behavior and occasional contacts with the legal authorities is, sadly, relatively commonplace in children with ADHD followed to adulthood (Barkley, Murphy, & Fischer, 2008; Satterfield, Faller, Crinella, Schell, Swanson, & Homer, 2007). This is particularly so for driving offenses, where available research shows teens and adults with ADHD to be at high risk for a variety of adverse outcomes (Barkley & Cox, 2007). Consequently, clinicians must take care to advise not only patients with ADHD but parents as well about the driving risks of teens and young adults with ADHD under their care and the need to take appropriate steps to address those risks, including the use of medication while driving.
As in this case, antisocial activities or contacts with legal authorities may be the basis for the referral for evaluation and often are the most impairing and distressing feature of the current presentation, at least to the patient’s loved ones, if not to the patient himself. And while ADHD, conduct disorder (CD; antisocial behavior), and psychopathy are distinct yet interrelated disorders/constructs (Pardini, Obradovic, & Loeber, 2006), and most cases of ADHD do not become adult psychopaths (Fowler, Langley, Rice, Whittinger, Ross et al., 2009), there is a greater likelihood of psychopathy in teens and adults with ADHD than is the case in the general population, especially if they had manifested symptoms of childhood conduct problems (Waschbusch & Willoughby, 2008). Given the strong contribution of psychopathic traits to persistence of antisocial behavior into and through adulthood (Fowler et al., 2009; Lynam, 1998) and the substantial genetic and neurological contributions to psychopathy (Blair, Peschardt, Budhani, Mitchell, & Pine, 2006), clinicians need to be on the alert for its existence in cases such as Pat’s, as it may bode for an even poorer outcome than would ADHD or CD alone. It may also increase the risk of harm to family members and others attempting to intervene with the patient. Thus it might have been useful in this case to screen for such traits using rating scales for this purpose.
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