Moodiness in ADHD: A Clinician's

Guide 1st Edition W. Burleson Daviss

Visit to download the full and correct content document:
https://textbookfull.com/product/moodiness-in-adhd-a-clinicians-guide-1st-edition-w-b
urleson-daviss/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Treating Adolescent Substance Use A Clinician s Guide

Justine W. Welsh

https://textbookfull.com/product/treating-adolescent-substance-
use-a-clinician-s-guide-justine-w-welsh/

A Clinician s Guide to Cannabinoid Science 1st Edition

Steven James

https://textbookfull.com/product/a-clinician-s-guide-to-
cannabinoid-science-1st-edition-steven-james/

The Therapeutic Relationship in Cognitive Behavioral

Therapy A Clinician s Guide 1st Edition Nikolaos
Kazantzis

https://textbookfull.com/product/the-therapeutic-relationship-in-
cognitive-behavioral-therapy-a-clinician-s-guide-1st-edition-
nikolaos-kazantzis/

The Dermatology Handbook A Clinician s Guide Neelam A.

Vashi (Editor)

https://textbookfull.com/product/the-dermatology-handbook-a-
clinician-s-guide-neelam-a-vashi-editor/
Clostridium Difficile Infection in Long Term Care
Facilities A Clinician s Guide Teena Chopra

https://textbookfull.com/product/clostridium-difficile-infection-
in-long-term-care-facilities-a-clinician-s-guide-teena-chopra/

A Clinician s Guide to Pemphigus Vulgaris 1st Edition

Pooya Khan Mohammad Beigi (Auth.)

https://textbookfull.com/product/a-clinician-s-guide-to-
pemphigus-vulgaris-1st-edition-pooya-khan-mohammad-beigi-auth/

A Clinician s Guide to Suicide Risk Assessment and

Management 1st Edition Joseph Sadek

https://textbookfull.com/product/a-clinician-s-guide-to-suicide-
risk-assessment-and-management-1st-edition-joseph-sadek/

Endocrine and metabolic medical emergencies a clinician

s guide Second Edition Matfin

https://textbookfull.com/product/endocrine-and-metabolic-medical-
emergencies-a-clinician-s-guide-second-edition-matfin/

Crisis, Trauma, and Disaster: A Clinician′s Guide Linda

Lutisha Black

https://textbookfull.com/product/crisis-trauma-and-disaster-a-
clinician%e2%80%b2s-guide-linda-lutisha-black/
Moodiness
in ADHD
A Clinician’s Guide

W. Burleson Daviss
Editor

123
Moodiness in ADHD
W. Burleson Daviss
Editor

Moodiness in ADHD
A Clinician’s Guide
Editor
W. Burleson Daviss
Department of Psychiatry
Dartmouth Hitchcock Medical Center
Dartmouth Geisel School of Medicine
Lebanon, NH, USA

ISBN 978-3-319-64250-5    ISBN 978-3-319-64251-2 (eBook)

https://doi.org/10.1007/978-3-319-64251-2

Library of Congress Control Number: 2017957057

© Springer International Publishing AG 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims
in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface

In addition to the key symptoms that characterize patients with attention deficit
hyperactive disorder (ADHD) (inattention, hyperactivity, and impulsivity), youth and
adults with ADHD frequently have difficulties regulating their mood. Unfortunately,
the Diagnostic and Statistical Manual (DSM) has omitted this ubiquitous symptom
that has important diagnostic, prognostic, as well as treatment implications. This fact,
however, was recently captured in the most recent International Classification of
Diseases (ICD) classification of psychiatric disorders.
In this book, Dr. Daviss and colleagues present a comprehensive review of the
existing literature regarding the presence of mood dysregulation in patients with
ADHD. Given that mood dysregulation is common in several disorders, the authors
provide a thorough evaluation of the epidemiology, etiology, phenomenology,
differential diagnosis, and tools and strategies for assessment of ADHD and a
variety of comorbid disorders. For example, the book includes chapters about
ADHD co-occurring with mood disorders, anxiety, disruptive behavior disorders,
substance abuse, autism, and medical illness. In addition, the book offers a chapter
specifically regarding adults with ADHD and mood lability.
Despite the scarcity of randomized controlled trials for ADHD with comorbid
disorders, the chapters also provide helpful suggestions regarding the pharmaco-
logical and psychosocial treatments for these conditions.
This book is highly recommended for clinicians as well as researchers treating or
studying patients with potential ADHD and mood lability.

Lebanon, NH, USA W. Burleson Daviss

v
Contents

1 Introduction: ADHD, Moodiness, Meteorology, and Elephants����������    1

W. Burleson Daviss
2 Assessment Strategies for Moody ADHD in Children, Adolescents,
and Adults������������������������������������������������������������������������������������������������    5
W. Burleson Daviss and Joseph Bond
3 Mood Disturbance in ADHD Due to a General
Medical Condition������������������������������������������������������������������������������������   25
John G. Ryder and Jacquelyn M. Silva
4 Comorbidity of ADHD with Anxiety Disorders and Obsessive
Compulsive Disorder ������������������������������������������������������������������������������   39
Alma M. Spaniardi, Renee C. Saenger, John T. Walkup, and Breck
Borcherding
5 Post-traumatic Stress Disorders and ADHD ����������������������������������������   55
Erin R. Barnett, Sarah E. Cleary, Katrin Neubacher,
and W. Burleson Daviss
6 Disruptive Mood Dysregulation, and Other Disruptive or Aggressive
Disorders in ADHD����������������������������������������������������������������������������������   73
Joseph C. Blader
7 Depressive Disorders and ADHD ����������������������������������������������������������   91
W. Burleson Daviss
8 Pediatric Bipolar Disorders and ADHD������������������������������������������������ 111
Rasim S. Diler
9 Autism Spectrum and Other Developmental Disorders
and ADHD������������������������������������������������������������������������������������������������ 129
Jennifer L. McLaren, Jonathan D. Lichtenstein, Sarah Y. Bessen,
and Fern Baldwin
10 Moodiness in Patients with ADHD and Substance Use Disorders������ 145
Oscar G. Bukstein and Aaron Roberto

vii
viii Contents

11 Moody Adults with ADHD���������������������������������������������������������������������� 161

Michael J. Silverstein, Samuel Alperin, Yonatan Hochstein,
and Lenard A. Adler

Index������������������������������������������������������������������������������������������������������������������ 187
Contributors

Lenard A. Adler, M.D. Department of Psychiatry, New York University Langone

School of Medicine, New York, NY, USA
Department of Child and Adolescent Psychiatry, New York University Langone
School of Medicine, New York, NY, USA
Samuel Alperin, M.D. Cincinnati Children’s Hospital Medical Center, Cincinnati,
OH, USA
Hofstra Northwell School of Medicine, Hempstead, NY, USA
Fern Baldwin, Ph.D. Department of Psychiatry, Geisel School of Medicine at
Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
Erin R. Barnett, Ph.D. Department of Psychiatry, Dartmouth Hitchcock Medical
Center, Dartmouth Geisel School of Medicine, Lebanon, NH, USA
Sarah Y. Bessen, M.P.H. Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
Joseph C. Blader, Ph.D. The University of Texas Health Science Center at San
Antonio, San Antonio, TX, USA
Joseph Bond, M.D. Department of Psychiatry, Dartmouth Hitchcock Medical
Center, Dartmouth Geisel School of Medicine, Lebanon, NH, USA
Breck Borcherding Weill Cornell Medicine, New York, NY, USA
NewYork-Presbyterian/Westchester Division, White Plains, NY, USA
Oscar G. Bukstein, M.D., M.P.H. Department of Psychiatry, Boston Children’s
Hospital, Boston, MA, USA
W. Burleson Daviss, M.D. Department of Psychiatry, Dartmouth Hitchcock
Medical Center, Dartmouth Geisel School of Medicine, Lebanon, NH, USA
Sarah E. Cleary, Ph.D. Department of Psychiatry, Dartmouth Hitchcock Medical
Center, Dartmouth Geisel School of Medicine, Lebanon, NH, USA
Rasim S. Diler, M.D. Western Psychiatric Institute and Clinic (WPIC) of
University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA

ix
x Contributors

Yonatan Hochstein, M.S. Department of Child and Adolescent Psychiatry, New

York University Langone School of Medicine, New York, NY, USA
Jonathan D. Lichtenstein, Psy.D., M.B.A. Department of Psychiatry, Geisel
School of Medicine at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon,
NH, USA
Jennifer L. McLaren, M.D. Department of Psychiatry, Geisel School of Medicine
at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
Katrin Neubacher, Psy.D. Trauma Center at Justice Resource Institute, Brookline,
MA, USA
Aaron Roberto, M.D. Department of Psychiatry, Yale School of Medicine,
New Haven, CT, USA
John G. Ryder, M.D., M.S. Department of Psychiatry, Dartmouth Hitchcock
Medical Center, Dartmouth Geisel School of Medicine, Lebanon, NH, USA
Renee C. Saenger Weill Cornell Medicine, New York, NY, USA
Jacquelyn M. Silva, M.D. Department of Pediatrics, Comer Children’s Hospital,
The University of Chicago, Chicago, IL, USA
Michael J. Silverstein, B.A. Department of Psychology, Drexel University,
Philadelphia, PA, USA
Department of Psychiatry, New York University Langone School of Medicine,
New York, NY, USA
Alma M. Spaniardi Weill Cornell Medicine, New York, NY, USA
NewYork-Presbyterian/Westchester Division, White Plains, NY, USA
John T. Walkup Department of Child and Adolescent Psychiatry, Ann & Robert
H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Introduction: ADHD, Moodiness,
Meteorology, and Elephants 1
W. Burleson Daviss

ADHD is one of the most common mental health disorders, with a prevalence of
approximately 8% in children and adolescents and 4–5% in adults in population
studies [1]. According to criteria from the Diagnostic and Statistical Manual of
Mental Disorders’ fifth edition [DSM-5; [2]], patients with ADHD by definition
have impairment in multiple functional domains, which can be life-long, especially
without treatment [1, 3, 4].
Patients of all ages with ADHD often have other comorbid disorders, both in
clinical and epidemiological samples [5–7]. Many such disorders have symptoms of
moodiness, variously described as irritability, dysphoria, depression, anxiety, anger,
mood dysregulation, affective lability, or explosive aggression. Some diagnoses are
limited to children or adolescents, including conduct or oppositional defiant disor-
ders. Depressive disorders can be diagnosed in all ages, but in children or adoles-
cents, irritability as well as depression or anhedonia can be the predominant mood
symptom, while irritability in adults is not a mood criterion for depression.
Disruptive mood dysregulation disorder is a new mood diagnosis added to DSM-5
limited to patients less than 18, and characterized by persistent irritable or angry
moods that are punctuated by recurrent temper outbursts several times a week [2].
Other disorders with moodiness or irritability can only be diagnosed in adults,
including borderline, histrionic, and narcissistic personality disorders, as well as
antisocial personality disorder (which is considered a continuation of juvenile con-
duct disorder) [2]. Finally, additional disorders with irritable or moody symptoms
can occur in patients of all ages, including bipolar disorders, cyclothymia, drug or
alcohol use disorders, autism spectrum disorders, or intermittent explosive disorders
[2]. All will be covered in various chapters in the current book.

W.B. Daviss, M.D. (*)

Department of Psychiatry, Dartmouth Hitchcock Medical Center,
Dartmouth Geisel School of Medicine, Lebanon, NH, USA
e-mail: william.b.daviss@dartmouth.edu

© Springer International Publishing AG 2018 1

W.B. Daviss (ed.), Moodiness in ADHD, https://doi.org/10.1007/978-3-319-64251-2_1
2 W.B. Daviss

While comorbid disorders are relatively common and account for much of the
moodiness seen in patients of all ages with ADHD, some experts have argued that
moodiness in adult ADHD is a core symptom of the ADHD itself [8, 9]. Others have
gone a step further to suggest that the presence of moodiness should be used to
define subtypes of ADHD, just as having inattentive or hyperactive/impulsive symp-
toms do [10, 11]. The section on ADHD in DSM-5, however, describes “low frustra-
tion tolerance, irritability, or mood lability” as “associated features” but not
diagnostic criteria of ADHD [2, p. 61]. Chapter 11 reviews various explanations of
emotional dysregulation in adult ADHD, along with their assessment, and
treatment.
Mental health clinicians are taught to use the term “affect” to describe patients’
immediate emotional tone, with signs and symptoms conveyed both verbally (with
changes in tone, volume, and rapidity) and nonverbally (with changes in facial
expressions, motoric activity, and body posture). Such signs of affect can change
from seconds to minutes. In contrast, the term “mood” is used to describe more
extended emotional states (e.g., anxious, depressed, manic) lasting days to weeks or
longer. Such moods color people’s views of themselves and their life experiences.
The relationship of “affect” to “mood” is considered analogous to that of “weather”
to “climate.” However, mood and affect are perhaps better described as existing on
a continuum. Moods change faster in patients with mental illnesses just as climates
change faster with greenhouse gasses. I have deliberately used the informal and
nonspecific term “moody” to capture this array of problematic emotional states,
both brief and extended.
My first experience working with child and adolescent psychiatric patients was
at a busy community mental health clinic, where I often saw patients with comorbid
ADHD. My experiences treating such patients were consistent with the literature,
which suggests that approximately 3 out of 4 respond to any stimulant tried when
dosed correctly [12]. Such work seemed a unique opportunity in psychiatry to “hit
a home run with the first pitch.” Eventually, as a child and adolescent psychiatry
fellow, the ADHD patients I saw in a tertiary mental health clinic at the University
of Utah had comorbid presentations at least two-thirds of the time, echoing the
comorbidity literature [13]. Such comorbidities included externalizing disorders
with outbursts of anger, defiance, and aggression. They also included internalizing
disorders with somatic/vegetative symptoms, excessive worry, poor self-esteem,
guilt, and hopelessness, suggesting the social and academic challenges such patients
experienced chronically because of their ADHD. An additional challenge was that
such patients often had parents with similar symptoms. Dr. Paul Wender and col-
leagues also at the University of Utah were working with many of these adult
patients, diagnosing and treating their ADHD, and challenging the conventional
wisdom at the time that ADHD did not extend into adulthood [10]. Adults who con-
tinued to have symptoms of ADHD often had co-occurring affective lability, which
Wender and colleagues labeled “emotional dysregulation,” and argued was an addi-
tional symptom of adult ADHD [10, 11]. These adult patients often had a dramatic
response regarding ADHD and emotional dysregulation when treated with
1 Introduction: ADHD, Moodiness, Meteorology, and Elephants 3

stimulants, and a marked improvement in their ability to function as parents, which

also improved the lives of their children who were frequently our patients.
My training experiences raised some questions. How could the various causes of
moodiness in pediatric or adult ADHD be more effectively diagnosed and treated?
Does effective treatment of their ADHD change these patients’ risk of developing
more severe externalizing and internalizing disorders later? Are there situations in
which treating the ADHD worsens patients’ moodiness and how can we anticipate
those? Conversely, could treating these patients’ mood and affective problems
lessen the impairment of their ADHD? Are the various diagnoses used to describe
mood symptoms in patients with ADHD truly distinct diagnoses, or are these simply
examples of us as blind clinicians feeling different parts of the same elephant?
The goals of the current book are to give clinicians the ability to start answering
some of the above questions, by providing a clinical framework and pragmatic tools
to improve their assessment and treatment of various sources of moodiness in
patients with ADHD. Authors of the various chapters were selected based on their
clinical and research expertise in their respective topics. The earliest two chapters
are devoted to general strategies for assessing ADHD and other comorbidities and
ruling out potential organic etiologies for them. Subsequent chapters focus on vari-
ous “flavors” of diagnoses associated with such moodiness, their epidemiology and
public health impact, etiological factors, and strategies for assessment and treat-
ment. Each chapter concludes with a summary of where things stand in that particu-
lar area, as well as key un-answered questions. Some chapters review disorders that
can occur at any age, others focus on disorders of children, and the last focuses on
disorders of adults.
Authors have written their chapters independent of each other, and as a result,
there may be some differences about frequencies of various disorders, or about rec-
ommendations for assessment and treatment between chapters. Even so, my goal is
to present a range of expert perspectives and opinions, some of which may be more
relevant or useful than others, depending on the reader’s clinical experiences and
interests. My hope by providing a review of the main causes of moodiness in indi-
viduals with ADHD is to help improve clinicians’ understanding, clinical skills and
confidence in caring for such patients.
I’d like to acknowledge the contributions of all of the authors of chapters in this
book. All have been generous with their time and diligent in writing their respective
chapters, reflecting their enthusiasm for their professional work as clinicians and
researchers. All have also been exceedingly patient with my sometimes compulsive
editorial suggestions. Thanks also to Cheryl Winters-Tetreau and Nadina Persaud
with Springer Publishing for their help and patience.
On a personal note, I’d like to thank the many patients and families who have
allowed me to treat them and learn from them. I’d also like to acknowledge the help
and inspiration I’ve had from multiple mentors and colleagues, including Steven
Pliszka, Kenneth Matthews, Douglas Gray, Bill MacMahon, Frances Burger,
Richard Fere, Boris Birmaher, James Perel, David Brent, Neal Ryan, Rasim Diler,
Charles Reynolds, Paul Pilkonis, Robert Drake, and Greg McHugo. Above all, I’d
4 W.B. Daviss

like to thank my parents, Dave and Claire, my lovely wife Betsy, and my children,
David, Madeline, Claire, Jessica and Sanna, for their love and encouragement. All
have supported and inspired me, and offered shining examples of how to approach
life and work with enthusiasm, grace, determination, and a sense of humor.
Thanks to you as a reader for your interest in this topic and good luck in your
work with these challenging but fascinating patients.

References
1. Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, et al. The prevalence
and correlates of adult ADHD in the United States: results from the National Comorbidity
Survey Replication. Am J Psychiatry. 2006;163(4):716–23.
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th
ed. Arlington: American Psychiatric Association; 2013.
3. Bernardi S, Faraone SV, Cortese S, Kerridge BT, Pallanti S, Wang S, et al. The lifetime impact
of attention deficit hyperactivity disorder: results from the National Epidemiologic Survey on
alcohol and related conditions (NESARC). Psychol Med. 2012;42(4):875–87.
4. Biederman J, Faraone SV, Spencer TJ, Mick E, Monuteaux MC, Aleardi M, et al. Functional
impairments in adults with self-reports of diagnosed ADHD: a controlled study of 1001 adults
in the community. J Clin Psychiatry. 2006;67(4):524–40.
5. Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 1999;40(1):57–87.
6. Biederman J. Impact of comorbidity in adults with attention-deficit/hyperactivity disorder.
J Clin Psychiatry. 2004;65(Suppl 3):3–7.
7. Chen MH, TP S, Chen YS, Hsu JW, Huang KL, Chang WH, et al. Higher risk of develop-
ing mood disorders among adolescents with comorbidity of attention deficit hyperactivity
disorder and disruptive behavior disorder: a nationwide prospective study. J Psychiatr Res.
2013;47(8):1019–23.
8. Corbisiero S, Morstedt B, Bitto H, Stieglitz RD. Emotional Dysregulation in adults with
attention-­
deficit/hyperactivity disorder-validity, predictability, severity, and comorbidity.
J Clin Psychol. 2017;73(1):99–112.
9. Barkley RA. Deficient emotional self-regulation: a core component of attention-deficit/hyper-
activity disorder. J ADHD Relat Disord. 2010;1(2):5–37.
10. Wender PH. Attention-deficit hyperactivity disorder in adults. New York: Oxford University
Press; 1995.
11. Marchant BK, Reimherr FW, Robison D, Robison RJ, Wender PH. Psychometric properties of
the Wender-Reimherr adult attention deficit disorder scale. Psychol Assess. 2013;25(3):942–50.
12. Spencer T, Biederman J, Wilens T, Harding M, O’Donnell D, Griffin S. Pharmacotherapy
of attention-deficit hyperactivity disorder across the life cycle. J Am Acad Child Adolesc
Psychiatry. 1996;35(4):409–32.
13. Pliszka SR. Patterns of psychiatric comorbidity with attention-deficit/hyperactivity disorder.
Child Adolesc Psychiatr Clin N Am. 2000;9(3):525–40, vii.
Assessment Strategies for Moody ADHD
in Children, Adolescents, and Adults 2
W. Burleson Daviss and Joseph Bond

Introduction

Mood and affect problems and symptoms of inattention, hyperactivity, and impul-
sivity are common in society, and particularly in mental health and primary care
settings. Such problems impair patients’ relationships with family and friends, their
academic and occupational function, and ultimately the course of their lives. Careful
and comprehensive assessment can lay the groundwork for effective treatments that
can be life-changing. The list of differential diagnoses is long, and includes mood
disorders, anxiety disorders, substance use disorders, personality disorders, and dis-
ruptive behavioral disorders, any of which can also have organic or substance-­
related etiologies. An effective initial interview will consider each of these groups
of potential causes for the presenting symptoms, but may require multiple addi-
tional steps to gather more information. Sources of such information will include
the patient and often other collateral informants, but may also include old medical,
mental health, employment and academic evaluations, and sometimes behavioral
comments on old report cards. Much of this information can be assimilated prior to
the clinician’s evaluation.
Often the clinician must integrate incomplete, potentially inaccurate, and some-
times contradictory information from different informants, and carefully weigh
such informants’ potential accuracy, biases, and motivations. Patients with ADHD,
by definition, are inattentive, hyperactive or impulsive, and may give inaccurate
answers, whether intentional or not. Patients or family members may underreport
the patient’s symptoms due to denial, poor insight, skepticism about mental ill-
nesses, discomfort with the patient being “labeled,” or simply to defy whichever
party requested the evaluation without their blessing. In children or adolescents,

W.B. Daviss, M.D. (*) • J. Bond, M.D.

Department of Psychiatry, Dartmouth Hitchcock Medical Center,
Dartmouth Geisel School of Medicine, Lebanon, NH, USA
e-mail: william.b.daviss@dartmouth.edu; joseph.b.bond@hitchcock.org

© Springer International Publishing AG 2018 5

W.B. Daviss (ed.), Moodiness in ADHD, https://doi.org/10.1007/978-3-319-64251-2_2
6 W.B. Daviss and J. Bond

such discordance may reflect parental conflicts with each other, with the patient, or
with the school. Patients with ADHD often tend to overestimate their competence in
various areas, a trait known as “positive illusory bias” [1, 2]. On the other hand,
patients or family members may overreport the patient’s symptoms when anxious or
depressed [3], to seek academic or occupational accommodations or a medical
excuse, or to obtain medications they hope will be therapeutic for the patient, or that
they may divert or misuse. The late US president, Ronald Reagan, when asked about
his confidence that his Russian counterparts would comply with a historical treaty
intended to reduce both countries’ nuclear arsenals, stated simply that he would
“trust, but verify.” Clinicians should use the same approach with information pro-
vided by patients and other informants, especially when their clinical observations
and gut feelings raise doubts.

 istory of Present Illness, Past History, Family History,

H
and Staging the Interview

For patients of all ages, proper psychiatric assessment will often require several
stages [4–6]. The first stage will generally include brief introductions with the
patient and other informants to review basic identifying information, chief com-
plaints, goals for the evaluation, and further stages. At that time, the clinician can
review aspects and limits of confidentiality. The next stages in the case of child or
adolescent patients involve interviewing the child/adolescent and parent separately.
This gives each party the chance to confidentially discuss their side of the story
about the reported problems, as well as other potentially sensitive issues, and for the
clinician to observe how reports, behaviors, and attitudes change when the other
informant is no longer present. This also gives the clinician the chance to compare
each party’s answers to similar questions. The time spent with each party will vary,
depending on the chief complaints, each party’s willingness to participate in a sepa-
rate interview, and the clinician’s opinion about the relative reliability of each party
in reporting their clinical concerns [6].
As a general rule, the proportion of time the clinician spends with a child or
adolescent patient will generally increase with the patient’s age, assuming he or she
is cooperative and judged to be a good informant [4–6]. However, even brief inter-
views with younger children can provide useful observations about their activity
level, mood and affect, developmental level, speech and language skills, and ability
to handle a brief separation from their parent or other caregiver [4]. Clinicians
should adjust their style and language level to the patient’s maturity, intelligence
and language skills [4, 5]. In young patients, it is particularly important to “break
the ice” by adopting a comfortable and reassuring demeanor and asking less prob-
ing questions first, perhaps about hobbies, activities, friendships, experiences in
school, and relationships with family [4, 5]. Any suggested problems can then be
followed up with questions about mood, anxiety, obsessive compulsive, psychotic,
and behavioral symptoms, and how those impact such activities. The individual
interview also provides the chance to ask about trauma exposure, sexual activity,
drug/alcohol use, suicidal ideations and behaviors, and other risky behaviors or
2 Assessment Strategies for Moody ADHD in Children, Adolescents, and Adults 7

potential safety concerns. Reassuring patients that these are routine questions asked
of all patients can make them more forthcoming in disclosing their problems and
concerns. Above all, close observation of the patient’s mood, affect, and behaviors
during the interview is critical. Feelings the patient evokes in the examiner (e.g.,
sadness, anxiousness, hopelessness, pity, irritation) often provide important clues
about patients’ underlying mood and thoughts [4, 5].
A similar approach in interviewing adult patients can be equally helpful, assum-
ing they have age-appropriate maturity, communication and cognitive skills. Finding
the proper balance between developing an alliance with the patient, and maintaining
proper boundaries and a neutral perspective can be especially important but tricky.
In adult patients who are the persons of interest, they should be allowed greater say
regarding what happens during the diagnostic process and the degree that other
informants may participate. The clinician, however, can also set limits when neces-
sary, especially since the diagnosis of ADHD requires such collateral information,
and when the patient’s thoughts and behaviors represent potential safety concerns.
How patients present themselves in the interview can also be quite informative.
Do they seem sincere and trustworthy? Are they appropriately dressed, with good
hygiene, or seem disorganized or disheveled? Do they seem distracted, spacey, or
forgetful? Do they show signs of hyperactivity such as fidgetiness, or impulsivity
such as answering questions prematurely? Do they report cognitive and vegetative
symptoms of depression or any signs and symptoms suggestive of mania or psycho-
sis? What kind of feelings do they evoke in you as the clinician through their behav-
iors and interactions: sympathy, irritation, anxiety, skepticism, fear? Do they have
appropriate feelings about their presenting complaints?
Time spent with the parents or other family members, either alone or with the
patient, is essential in the case of child and adolescent assessments, and often help-
ful in the case of adult patients too. Parents and other family members will often be
more reliable reporters regarding the patient’s ADHD and other externalizing
behaviors, and other potentially sensitive issues about the patient’s substance use,
and social, school, work, family, or legal problems. Parents often will be better able
to provide past psychiatric, medical, family, and socio-developmental history as
well as relevant stressors or trauma exposure that the patient has no awareness of, or
has chosen to withhold [6]. The clinician may use separate time with only the parent
of a child patient to share clinical impressions and propose next steps regarding
assessment and treatment of the patient. This is often a good time to discuss making
sure that the parent’s or other family members’ mental health needs are also being
appropriately addressed. Such time with parents and other family members helps
the clinician to anticipate potential problems the patient or parent could have in both
accepting and complying with the clinician’s recommendations for treatment.
Additional information about the patient’s past psychiatric history from the
patient or family can also be helpful, including past diagnoses, experiences with
prior therapy or pharmacological treatments, suicide attempts or self-injury, hospi-
talizations and the indications for them. If considering pharmacotherapy, it is impor-
tant to review any prior medications tried and the patient’s response to them. Careful
review of past medical history and reports of any current somatic symptoms could
suggest a tendency to overreport physical complaints that could be blamed as a
8 W.B. Daviss and J. Bond

medication side effect, or could suggest a potential medical problem that could
interfere with treatment, or at least require a medical workup and medical clearance
before starting pharmacotherapy.
Information about the family history, from either the patient or parent, is also
useful in understanding the patient’s current mental health issues and the environ-
mental context in which they are occurring. Identifying past mental health issues in
other family members can help to identify genetic risks for mood, ADHD, sub-
stance use, and autism spectrum disorders, as well as for suicidal behaviors.
Information about family members’ responses to pharmacological treatments can
be helpful in anticipating the patient’s responses to the same or similar medications.
A family member at home with an active substance use problem could increase the
patient’s risk of environmental adversities and trauma exposure, and is a relative
contraindication to prescribing controlled substances like stimulants to the patient.

The Physical and Mental Status Examination

Obtaining vital signs, including blood pressure, pulse, weight, and height, is recom-
mended as a routine part of psychiatric care, especially when considering a trial of a
stimulant medication or other ADHD medication. If considering a trial of an atypical
neuroleptic, baseline tests, such as an Abnormal Involuntary Movements Exam and
measurement of waist circumference, as well as ordering a fasting blood glucose and
lipids are recommended [7]. Observations of either motor or vocal tics are important
to document and potentially discuss with the patient and family. When considering
pharmacological treatment for ADHD, especially with a stimulant, a complete base-
line physical exam is recommended, since hypertension, tachycardia, and structural
or other heart problems are potential contraindications to such a trial [8, 9].

Structured Interviews and Rating Scales

As summarized in Table 2.1, there are several well-validated structured or semi-­

structured interviews to help clinicians’ reach more accurate diagnoses in patients
of all ages. Though such interviews are considered the gold standard for mental
health assessment, they are often time-consuming, impractical in clinical settings,
and require training to be used validly.
Instead, the current standard of care for patients of all ages is a careful diagnostic
interview, supplemented with collateral information from validated rating scales,
screening for various diagnoses that could explain patients’ presenting complaints,
or may require additional attention. Table 2.2 lists multiple different rating scales,
along with relevant references. Using additional time during the interview to gather
more information about symptoms reported on the questionnaires can be especially
helpful. Reports by interview or rating scales about trauma exposure and other
recent or ongoing stressors are especially important because they suggest contribut-
ing factors that could be targeted and mitigated with psychosocial interventions.

Table 2.1 Structured and semi-structured diagnostic interviews
Measure name
Kiddie Schedule for Affective
Disorders and Schizophrenia for
school-age children- Present and
Lifetime DSM-5 Version
(K-SADS-PL) [17]
Diagnostic interview for children
and adolescents (DICA) [18]
Diagnostic Interview Schedule
for Children (DISC) [19]
Mini International
Neuropsychiatric Interview for
Children and Adolescents
(MINI-KID) [20]
Structured Clinical Interview for
DSM-5 (SCID-5) [21]
Structured Clinical Interview for
DSM-5 Personality Disorders
(SCID-PD) [22]
Composite International
Diagnostic Interview (CIDI) [23]
DSM Diagnostic and Statistical Manual, PR Parent report, SR Self Report, Sxs symptoms, TR Teacher report, Yrs years
2
Patient_age
informants Contents Comments
6–18 years Multiple sections to assess mood disorders, anxiety, A widely used semi-­structured interview
SR disorders, psychotic disorders, trauma-related disorders, for clinician researchers; child and parent
PR eating disorders, substance use, and global assessment of interviewed separately, then together to
functioning; comprehensive except that it does not contain resolve differences in reported sxs.
an autism section Available at no cost
6–18 years Structured interview, which can be used by trained Available in a computer administered form
SR lay-interviewer; multiple sections separately screen patient in which patient reads the questions
PR and parent for various diagnoses based on DSM-criteria
for pediatric psychiatric disorders
9–17 years Structured interview containing multiple sections. Positive Used by lay-interviewers with training
SR screening items open up sections for closer review. Computerized version available that reads
PR Screens for over 30 psychiatric diagnoses in DSM-IV questions aloud
6–17 years Short battery of questions based on general categories of Parent and child interviewed together for
SR psychiatric sxs as described in DSM-IV; meant to take less most items, but child/adolescent
PR than an hour to interview both child and parent interviewed alone for items that may be
uncomfortable to endorse with parent
present
18+ years Thorough assessment that can take a half hour to 2 h to This is the most commonly used
SR administer depending on how many screening items are diagnostic interview and has versions for
endorsed clinicians (SCID-CV) and for clinical
trials (SCID-CT)
18+ years Screening questions based on criteria for all personality Adaptation of the SCID used to diagnose
SR disorders described in DSM-5 personality disorders; time personality disorders
required 30″
Assessment Strategies for Moody ADHD in Children, Adolescents, and Adults
18+ years Questions regarding 276 sxs related to DSM-IV diagnostic From the WHO website, but scoring
SR criteria requires special training
9

Table 2.2 Rating Scales and Questionnaires
Measure name
Attention deficit hyperactivity, oppositional defiant and conduct disorders
Vanderbilt Parent and Teacher 11–18 years
Behavioral Scales [24, 25]
Conners Comprehensive
Behavior Rating Scales
(CBRS) [26]
Short SNAP-IV [27]
Adult ADHD Self-report
Scale (ASRS) [28, 29]
Conner’s Adult ADHD
Rating Scales (CAARS) [30] SR
The Brown Attention-Deficit
Disorder Scale (BADDS) for SR or
Adults [32]
Behavioral Rating Inventory
of Executive Function
(BRIEF-A) [33]
Patient age informants Contents
55 questions on parent version and 43 questions on
PR teacher version. Questions assess sxs of ADHD
TR (inattentive and hyperactive clusters), ODD, Conduct
Disorder, depression, anxiety, and functional
impairment; based on DSM criteria; items considered
positive if rated at least “often”
8–18 years for An extensive instrument intended for multiple
CBRS-SR; informant types to provide a full review of behaviors,
6–18 years for CBRS-PR emotions, and academic/social function
and CBRS-TR
6–18 years 26-item version of original 90-item SNAP-IV;
PR Questions screen for ADHD and ODD sxs per
TR DSM-IV
18+ 18 questions based on DSM-IV criteria for
SR ADHD. Part A Screen: 4 inattentive and 2 hyper/
impulsive sxs; Part B has 12 remaining sxs
18+ years 26-item and 66-item forms measuring ADHD and
related sxs on 4-point scale. Subscales: Inattention-
Memory, Hyperactive-Restlessness; Impulsivity-
Emotional lability subscale measures sxs of ED [31].
18+ years Developed and normed to assess for poor executive
function and ADHD sxs; 40 items rated on a 4-point
clinician-­administered scale
18+ years 75 items of executive function and self-regulation
SR scored on a 3-point scale [33]; gives an overall
Other informant report Global Executive Composite score, a Behavioral
Regulation Index (with Emotional Control and 3
other component scales); and a Metacognition Index
(of executive function and ADHD). Raw scores can
convertible to standard T scores
10
Comments
Teacher version combines ODD and
Conduct disorder questions into single
group; helpful in diagnosis process,
treatment-­sensitive; no cost
Clinical Index is an auxiliary scale
used to help review sxs for specific
DSM disorders
Sxs rated “often” or “very often” are
counted positive. No cost
The 6 Part A items are best
discriminators of adult ADHD
Long form has an Inconsistency Index
that measures differing answers to
similar questions
Emotional Control cluster for
frustration management and emotional
modulation
T-scores of 50 equivalent to
population’s mean, and T-scores ≥65
are 1.5 standard deviations above it,
and suggest the problems are
clinically significant [34]
W.B. Daviss and J. Bond
Measure name
Objective measures of ADHD
Conners Continuous
Performance Test-II [11]
Test of Variable Attention
(TOVA) [12]
NEBA EEG-Based Test [15]
General measures of symptoms, dysfunction, and change with treatment
Achenbach System of
Empirically Based
Assessment (ASEBA) [39]
Strength and Difficulties
Questionnaire [41]
Columbia Impairment Scale
[42]
Patient age informants Contents
8 years to adult A 14″ computerized challenge, in which patients are
Task-based given a series of letters at varying intervals and told
to push the space bar whenever they see any letter
other than “X.” Measures errors of omission,
commission, and declining accuracy over time of test,
each suggesting possible ADHD
4 years to adult 22 min computerized assessment for ages 6 and up.
Task-based Ages 4–5 can take an 11 min test instead
6–18 years Uses modified EEG to measure electrical activity in
20–30″ the front part of the brain, specifically the ratio of
theta to beta waves, which has been found to be a
biomarker of potential ADHD [16]. Results
categorize youths as: (1) is likely to have ADHD, (2)
needs additional assessment for ADHD sxs, and (3)
needs additional assessment for “other conditions”
1.5–5 years for pre- 4 pages of 100 or more questions about general level
school PR; of functioning, and questions about problematic
6–18 years for School behaviors. Behaviors included are: Aggressive,
age PR or TR; anxious/depressed, attention problems, rule-­breaking
11–18 years for Youth behavior, somatic complaints, social problems,
SR thought problems, and withdrawn/depressed. All
versions take about 30″ to complete
2 years to adult 25 items in five categories: Emotional sxs, conduct
SR problems, hyperactivity/inattention, peer
PR relationships, pro-social behaviors
TR
9–17 years 13 items related to interpersonal relations,
SR or PR occupation, schoolwork, use of leisure time, and
affect. Originally meant to done by interview
Comments
2
Provides a score suggesting relative
likelihood of ADHD; moderate
correlation with parent- and teacher
ADHD ratings; treatment-­sensitive to
ADHD meds [35–38]
As with CPT-II above, lacks
sensitivity and specificity, but is
treatment-­sensitive
Unclear if treatment-­sensitive
Available in >90 languages with
normative data from multiple different
societies. The previous version was
the Child Behavior Checklist (CBCL)
[40]
Widely used in clinical settings and
studies, especially in Europe; multiple
Assessment Strategies for Moody ADHD in Children, Adolescents, and Adults
translations available; no cost
More recently used as a questionnaire;
no cost
11
(continued)

Table 2.2 (continued)
Measure name
Clinician Global Impressions
of Severity Scale (GGI-S)
[43]
Clinician Global Impressions
of Improvement Scale
(GGI-I) [43]
Mood disorders
Patient Health Questionnaire
(PHQ-9) [45]
PHQ-9 for Adolescents [46]
Mood and Feelings
Questionnaires (MFQ) [47]
Children’s Depressive Rating
Scale, Revised (CDRS-R)
[50]
Beck Depressive Inventory
Version 2 (BDI-2) [51]
Patient age informants Contents
All ages Widely used in research and clinical practice to
Clinician-rated estimate assess baseline severity and changes over time. Rater
of clinical severity uses all available clinical info including clinical
relative to other patients observations. CGI-S ratings from 1 to 7: (1) Normal,
with that diagnosis not at all ill; (2) Borderline mentally ill; (3) Mildly
ill; (4) Moderately ill; (5) Markedly ill;
(6) Severely ill; (7) Among the most extremely ill
All ages. Companion measure to CGI-S, used to assess
Clinician-rated estimate response to treatment. CGI-I ratings from 1 to 7: (1)
of clinical improvement very much improved; (2) much improved; (3)
from baseline minimally improved; (4) no change; (5) minimally
worse; (6) much worse, and (7) very much worse).
Responders often defined in trials by a CGI-I ≤2
18+ years None questions about frequency of MDD sxs per
SR DSM-5 criteria. No cost
13–18 years for SR 13-item measure, with 9 DSM-based sxs of major
6–18 years for PR depression rated on 4-point scale according to
frequency
8–18 years 33 items scale, rating current depressive sxs on a
SR or PR versions 3-point scale: 0 = “not true,” 1 = “sometimes,”
2 = “true.” Treatment-sensitive; 6–7 year olds can
also complete if adult reads the questions [48]
8–18 years 17-item interview-rated, based on input from both SR
SR and PR. Ratings are on a 5- or 7-item scales. Widely
PR used in research to track changes in the severity of
depressive sxs
13+ years 21 items rated on a 3-point scale to assess DSM-IV
SR criteria for depression, created for adult use
12
Comments
Suggested by the Texas medications
algorithm group to track patients’
responses to various treatments, and to
guide further treatment decisions. No
cost [44]
Persistent CGI-I of 5 or 6 suggests the
need to consider a change treatment.
No cost [44]
Useful self-­administered screening
tool, quick to complete and score
Modified from Adult PHQ-9 to screen
for frequency of DSM-5 major
depression sxs. No cost
13-item version also available [49]
Score ≥40 indicate clinically
significant sxs; score <28 used to
define depressive remission
Occasionally used in studies with
adolescents
W.B. Daviss and J. Bond
Measure name Patient age informants Contents Comments
2

Children’s Depressive
Inventory (CDI) [52]
Center for Epidemiologic
Studies Depression Scale
(CESD) [53]; CESD-Revised
(CESD-R) [54]
Parent General Behavior
Inventory (P-GBI) [55];
Brief P-GBI Mania Scale
(GBI-10) [56]
Child Mania Rating Scale
[58, 59]
Young Mania Rating Scale
[60]
Young Mania Rating
Scale-­Parent Version [55]
The Mood Disorders
Questionnaire (MDQ)
adolescent version [61]
Mood Disorders
Questionnaire, Adult-version
[62]
Hamilton Depression Rating
Scale (HRDS or HAM-D)
[63, 64]
7–18 years 27 items on a 3-point scale. Modeled after BDI, to
SR assess depressive sxs in juveniles
18+ years 20 items measure the frequency of 9 depressive sxs as
SR defined by DSM-IV. Developed for adults but has
been used in adolescent studies; can be administered
by phone
5–17 years The 73-item P-GBI, includes a 28-item Hypomanic/
PR Biphasic and 45-item Depressive subscales.
Hypomanic/Biphasic subscale strongly discriminates
pediatric bipolarity from ADHD or other
psychopathology. Treatment-sensitive [57]
9–17 years 21-item screen for current sxs of mania based on
SR and PR DSM-IV. 10-item short form also available
9–17 years 11 questions based on DSM criteria for mania in
Clinician-rated YMRS; adults, later modified to be applicable in youths.
Also a PR version Newer parent-version enables them to report on
potential manic signs/symptoms in juveniles
11+ years Both adolescent SR and PR versions have 13 items
PR related to manic sxs, plus additional items to
SR determine if sxs occurred concurrently, and were
impairing; associated with significant impairment
18+ years 13 items of manic sxs, plus additional items assess if
SR reported sxs were concurrent, and significantly
impairing
18+ years The original has 17 questions to assess depressive sxs
PR but the most recent revision contains 29 questions
Treatment-­sensitive
No cost
A 10-item brief version of P-GBI
(GBI-10) also a valid screen for
pediatric mania [56]
Does not assess for lifetime mania. No
cost
Often used as an outcome measure in
trials of bipolar patients of all ages.
No cost
Modified from adult MDQ; only PR
version validated for identifying
bipolar youth; no cost
Instead of current sxs, screens for
lifetime history of manic sxs
No cost
Widely used in adult clinical trials,
treatment-­sensitive
Assessment Strategies for Moody ADHD in Children, Adolescents, and Adults

(continued)
13

Table 2.2 (continued)
Measure name
Anxiety disorders
Multidimensional Anxiety
Scale for Children (MASC)
[65]
Screen for Child Anxiety-
Related Disorders (SCARED)
[66]
Zung Self-Rating Anxiety
Scale (SAS) [67]
Generalized Anxiety Disorder
7 (GAD7) [68]
Obsessive compulsive disorder
Children’s Yale-Brown
Obsessive Compulsive Scale
(CY-BOCS) [69]
Short Leyton Obsessional
Inventory for Children and
Adolescents [72]
Obsessive-­Compulsive
Inventory-Child Version [74]
Obsessive-­Compulsive
Inventory-Revised [76]
14
Patient age informants Contents Comments
Child and adolescent 39 items classified by four domains of sxs: Physical Widely used, commercially available
SR (tense/restless and somatic/autonomic), social anxiety under copyright
(humiliation/rejection and public performance fears),
harm avoidance (perfectionism and anxious coping),
and separation anxiety
8–18 year 41 items: Generalized Anxiety, Panic Disorder, Specific scores for sub-­categories
SR and PR versions Separation Anxiety, Social Anxiety, and School suggest positive screens; no cost
Avoidance
18+ years 20-item, with four groups of sxs: Cognitive, Widely available
SR autonomic, motor
Adolescent and adult 7 items that screen for generalized anxiety disorder, Often used in Primary Care (has also
SR rated on 4-point scale been used in adolescents); no cost
Child or adolescent Informants first identify OCD sxs from a long list A pediatric version modeled after the
Clinician-­administered provided by the clinician, then are asked to rate the adult Yale-Brown Obsessive
child- or parent-rated most sxs based on their severity and levels of Compulsive Inventory [70]; used in
interview interference clinical trials and clinical practice [71]
8–18 years 11-item, abbreviated version of the 20-item Leyton Brief; separates OCD cases from
PR Obsessional Inventory-Child Version; OCD sxs rated depressed and community controls; no
SR on a 4-point scale. Modified from OCD measure in cost [71]
adults [73]
7–17 years A relatively new, child-version of the Obsessive- Enables brief assessment of pediatric
21-items; a SR or PR Compulsive Inventory (OCI-CV); 6 domains of sxs OCD across multiple domains of sxs
screen for OCD like original adult measure; scores correlate with [75]
clinician-rated OCD severity; treatment-sensitive
18+ years 18 items rated on a 5-point scale, summed to generate Total scores reported to correlate with
SR a total score. Contains six subscales: Washing, clinician-rated measures of OCD
checking, ordering, obsessing, hoarding, and mental severity
W.B. Daviss and J. Bond
neutralizing; treatment-sensitive [71]
Measure name Patient age informants Contents Comments
2

Yale-Brown Obsessive Adult 10-item scale; Patient first reviews a list of OCD sxs, Used in OCD research and clinical
Compulsive Scale [70] Clinician-rated, 10-item then rates the severity of impairment related to these treatment; no cost
scale sxs, with impairment from obsessions and
compulsions rated separately; treatment-sensitive
Trauma-related disorders
Clinician-­Administered 18+ years 30-item interview of recent (weekly and monthly Currently a gold standard for
PTSD Scale for DSM-5 SR versions) and lifetime sxs, frequency, and impairment assessing for PTSD at no cost
(CAPS-5) [77]; 11–18 related to DSM-5 criteria A-G for PTSD; New Child/
SR and PR Adolescent version also available (CAPS-CA-5) [78]
Traumatic Events Screening 8+ years for SR Items ask about lifetime history of 14 types of events Victimization events linked with
Inventory (TESI) [79] Any age for PR and level of distress (e.g. disasters, wrecks, illness, depression and suicidal behaviors [79,
domestic violence, community violence, physical 80]; no cost
abuse, sexual assault, etc.); measures non-­
victimization and victimization events
Life Events Checklist for 8+ years 16 items regarding occurrence of different potentially
DSM-5 [81] SR traumatic events
UCLA PTSD Reaction Index 7–12 years for Child SR Based on DSM-5 criteria; 33 items about traumatic Common outcome measure in
for DSM-5 [82] 13–18 years for events, and patient’s immediate and persistent pediatric PTSD research
Adolescent SR reactions. 18 items asked by clinician, 15 by patient
Trauma Symptom Checklist PR for all ages 54 questions in SR and 90 in PR. Child asked to
for Children/for Young SR for 8–16 years describe frequency of thoughts, feelings, behaviors
Children [83]
Child PTSD Symptom Scale 8–18 years 26 items related to traumatic events, PTSD sxs,
[84] SR impairment; based on DSM-IV criteria
Young Child PTSD Checklist 1–6 years 12 questions about the occurrence of traumatic events
[85] PR and 30 questions about specific sxs
PTSD Checklist for DSM-5 18+ years 20-item measure based on diagnostic criteria for No cost
Assessment Strategies for Moody ADHD in Children, Adolescents, and Adults

(PCL-5) [86] SR PTSD from DSM-5; military and civilians versions

(continued)
15

Table 2.2 (continued)
Measure name
Autism spectrum disorders
Modified Checklist for
Autism in Toddlers
(M-CHAT) revised [87]
Social Responsiveness Scale
version 2 (SRS2) [88]
Gilliam Autism Rating Scale
3rd Edition (GARS-3) [89]
The Autism Diagnostic
Observation Schedule, 2nd
Edition (ADOS-2) [90]
Substance use disorders
Child CRAFFT
Questionnaire [91]
Alcohol Use Disorder
Identification Test—
Consumption (AUDIT-C)
[92]
Patient age informants Contents
16–30 months Widely used screening to assess for risk for autism
20-item parent/caregiver spectrum disorders. Often administered and scored as
report part of a well-child check-up; On-line version too
4–18 years Dimensional measure of social ability; 5 subscales
PR and TR (both have 65 (Social Awareness, Social Cognition, Social
items) Communication, Social Motivation, Restricted
interests/Repetitive Behaviors), consistent with
DSM-5 criteria of Autism Spectrum Disorder
3–22 years 56 items, 6 subscales (Restrictive/Repetitive
PR and TR Behaviors, Social Interaction, Social Communication,
Emotional Responses, Cognitive Style, Maladaptive
Speech; sxs updated based on DSM-5 criteria for
autism spectrum disorders
Toddlers-adults Semi-structured, play based; assesses
50″ clinician-­ communication, social interaction, play, and
administered, interview restricted/repetitive behaviors, using specific tasks to
with patient alone elicit certain behaviors; objective; standardized;
requires training to use validly
12–18 years 9-question screening tool to assess exposure to, use
SR of, and consequences from drug use. Easy to
administer and score with high sensitivity; newest
CRAFFT 2.0 version asks about specific substances
Any age Three questions scored according to frequency of
alcohol use. The higher the score, the more likely an
alcohol use disorder (AUD) is present
16
Comments
Allows parent and clinician to
estimate autism risk. No cost
Generates raw scores, and T-scores
based on normative samples; can
assess syndromal and sub-­syndromal
cases
Total and subscale scores suggest
probability of an autism spectrum
disorder and severity of sxs; Yields
raw and T-scores
Offers age-­specific information for
equivocal cases of autism
Acronym for high risk behaviors: Car,
Relax, Alone, Forget, Friends,
Trouble. No cost
Positive screens:
4+ for men and 3+ for women; no cost
W.B. Daviss and J. Bond
Measure name
CAGE Questionnaire [93]
Opioid-Related Behaviors in
Treatment (ORBIT) Scale
[94]
Drug Abuse Screening Test
(DAST) [95]
Short Michigan Alcohol
Screening Test (SMAST)
[96]
Emotional Dysregulation
The Wender-­Reimherr Adult
Attention Deficit Disorder
Scale (WRAADDS) [97]
Behavior Rating Inventory of
Executive Function for Adults
(BRIEF-A) [33]
Emotional Impulsiveness
Scale (EIS) [101]
CNS central nervous system, DSM Diagnostic and Statistical Manual, EEG electroencephalogram, PR Parent report, SR Self Report, Sxs symptoms, TR Teacher
report, Yrs years
Patient age informants Contents Comments
2
Any age Four questions screening for the likelihood of AUD: No cost
SR Cut down, Annoyed, Guilty, and Eye-­opener; CAGE
alludes to topics of the 4 questions
18+ years 10 items track recent behaviors related to opioid use
SR (both aberrant use and clinical use)
Adolescent and adult SR 10, 20, or 28-item screens for substance abuse Moderate to high validity, sensitivity,
versions and specificity; no cost
Various SR versions by 10 to 24 item versions Shorter versions less specific but still
age sensitive in detecting alcohol
disorders; no cost
18+ years Based on the Utah Criteria, which view inattention Emotion Dysregulation Scale is sum
Clinician-­administered and hyperactivity, but not impulsivity, as the core sxs of scores on Emotional overreactivity,
scale of ADHD [97–99]. Assesses multiple sxs within Mood lability, and Temper; no cost
seven symptom domain categories: Difficulties [100]
sustaining attention, Disorganization. Hyperactivity/
restlessness, Impulsivity, Temper, Mood lability, and
Emotional over-reactivity
18+ years 75 items scored on a 3-point scale; categories include
SR Emotional Control and Metacognition
18+ years Screens for 7 sxs of emotional dysregulation:
SR (1) impatient; (2) quick to anger; (3) easily frustrated;
Other informant (4) over-reacts; (5) easily excited; (6) loses temper;
(7) touchy/easily annoyed
Assessment Strategies for Moody ADHD in Children, Adolescents, and Adults
17
18 W.B. Daviss and J. Bond

 europsychological, Continuous Performance,

N
and Electroencephalogram (EEG) Tests

Although neuropsychological testing has been suggested to be an important poten-

tial component of the workup for ADHD in patients of all ages [10], such testing is
often time-consuming and expensive, and not designed specifically to diagnose
ADHD at any age according to both the American Academy of Pediatrics [9] and
the American Academy of Child and Adolescent Psychiatry [8]. However, neuro-
psychological testing can be helpful in situations in which an underlying learning
disorder or developmental language disorder is suspected, or when accommoda-
tions at school or in taking standardized tests are being considered. If possible, this
could be done through the school’s special education team as it can be quite expen-
sive and insurance may not cover it.
Multiple continuous performance tests have been available for years [11, 12],
and are sometimes used in the assessment of potential individuals with ADHD of all
ages. A recent literature review of the available options suggested they often have
shown problems with retest reliability and in discriminating patients with and with-
out ADHD, due to unacceptably high false positive and false negative tests, espe-
cially in the presence of comorbid psychiatric disorders or other brain problems
[13]. Continuous performance tests are not a substitute for a good clinical interview.
However, they have been treatment-sensitive in pharmacological trials of ADHD
medications [14]. Table 2.2 has additional information about these too.
A test involving EEGs (known as NEBA) has recently been validated, and
approved by the Food and Drug Administration, as a supplemental test for ADHD
in children and adolescents [15]. The NEBA test involves an approximately 25 min
EEG in which the patient’s ratio of theta to beta waves is determined. This ratio has
been demonstrated to be a biomarker of ADHD [16], and may be useful in equivocal
cases. See Table 2.2 for more information.

Summary and Next Steps

A careful psychiatric assessment is the cornerstone for diagnosing and effectively

treating ADHD and the many disorders of moodiness associated with it. This
requires a carefully staged interview of the patient and other key informants about
the patient’s recent past history of mental health problems. Such interviews vary
according to age, cooperativeness, and perceived ability of the patient and other
informants to provide useful and accurate information about the reported problems.
Rating scales about patients’ symptoms and associated impairment can help in
screening, and guiding the interview, and may highlight and help to resolve contra-
dictory reports. Once working diagnoses are determined, rating scales can be used
subsequently to monitor changes in the patient’s symptoms with treatment, and to
help guide further adjustments to the treatment. The next chapter will review poten-
tial organic causes of moodiness and ADHD symptoms. Later chapters will discuss
assessment and treatment strategies for various potential causes of moodiness or
mood problems in patients with ADHD.
2 Assessment Strategies for Moody ADHD in Children, Adolescents, and Adults 19

References
1. Hoza B, Waschbusch DA, Pelham WE, Molina BS, Milich R. Attention-deficit/hyper-
activity disordered and control boys’ responses to social success and failure. Child Dev.
2000;71(2):432–46.
2. Evangelista NM, Owens JS, Golden CM, Pelham WE. The positive illusory bias: do inflated
self-perceptions in children with ADHD generalize to perceptions of others? J Abnorm Child
Psychol. 2008;36(5):779–91.
3. Shea K, Daviss WB. Caregiver depressive symptoms predict discrepancies between care-
giver, teacher, and youth ratings of psychopathology in adolescents with ADHD. Poster,
60th annual meeting of the American Academy of Child and Adolescent Psychiatry, 2013,
Orlando, FL.
4. Kestenbaum CJ. The clinical interview of the child. In: Dulcan MK, Wiener JM, editors.
Essentials of child and adolescent psychiatry. Arlington: American Psychiatric Publishing;
2006. p. 39–48.
5. King RA, Schowalter JE. The clinical interview of the adolescent. In: Dulcan MK, Wiener
JM, editors. Essentials of child and adolescent psychiatry. Arlington: American Psychiatric
Publishing; 2006. p. 49–56.
6. Leventhal BL, Crotts ME. The parent interview essentials of child and adolescent psychiatry.
Arlington: American Psychiatric Publishing; 2006. p. 57–66.
7. Correll CU, Penzner JB, Parikh UH, Mughal T, Javed T, Carbon M, et al. Recognizing and
monitoring adverse events of second-generation antipsychotics in children and adolescents.
Child Adolesc Psychiatr Clin N Am. 2006;15(1):177–206.
8. Pliszka S, AACAP Work Group. On quality issues. Practice parameter for the assessment
and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am
Acad Child Adolesc Psychiatry. 2007;46(7):894–921.
9. American Academy of Pediatrics Subcommittee on ADHD. ADHD: clinical practice guide-
line for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in
children and adolescents. Pediatrics. 2011;128(5):1007–22.
10. Pritchard AE, Nigro CA, Jacobson LA, Mahone EM. The role of neuropsychologi-
cal assessment in the functional outcomes of children with ADHD. Neuropsychol Rev.
2012;22(1):54–68.
11. Conners CK. Conners’ Continuous Performance Test-II (CPT-II) computer program for win-
dows technical guide and software manual. Toronto: Multi-Health Systems Inc.; 2000.
12. Greenberg LM. The Test of Variables of Attention (Version 8.0) [Computer software]. TOVA
Company: Los Alamitos; 2011.
13. Gualtieri CT, Johnson LG. ADHD: is objective diagnosis possible? Psychiatry (Edgmont).
2005;2(11):44–53.
14. Losier BJ, McGrath PJ, Klein RM. Error patterns of the Continuous Performance Test in
non-medicated and medicated samples of children with and without ADHD: a meta-analytic
review. J Child Psychol Psychiatry. 1996;37(8):971–87.
15. Snyder SM, Rugino TA, Homig M, Stein MA. Integration of an EEG biomarker with a clini-
cian’s ADHD evaluation. Brain Behav. 2015;5(4):e00330.
16. Snyder SM, Hall JR. A meta-analysis of quantitative EEG power associated with attention-­
deficit hyperactivity disorder. J Clin Neurophysiol. 2006;23(5):440–55.
17. Kaufman J, Birmaher B, Axelson D, Perepletchikova F, Brent D, Ryan N. K-SADS-PL
DSM-5. Pittsburgh: Western Psychiatric Institute and Clinic; 2016.
18. Reich W, Welner Z, Herjanic B. Diagnostic Interview for Children and Adolescents
(DICA-IV) Windows Version: Software Manual for Child/Adolescent and Parent Versions.
Multi-Health Systems: North Tonawanda; 1997.
19. Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME. NIMH Diagnostic Interview
Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous
20 W.B. Daviss and J. Bond

versions, and reliability of some common diagnoses. J Am Acad Child Adolesc Psychiatry.
2000;39(1):28–38.
20. Sheehan DV, Sheehan KH, Shytle RD, Janavs J, Bannon Y, Rogers JE, et al. Reliability and
validity of the Mini International Neuropsychiatric Interview for Children and Adolescents
(MINI-KID). J Clin Psychiatry. 2010;71(3):313–26.
21. First MB, Williams JBW, Karg RS, Spitzer RL. Structured Clinical Interview for DSM-5
Disorders, Clinician Version (SCID-5-CV). Arlington: American Psychiatric Association;
2015.
22. First MB, Williams JBW, Benjamin LS, Spitzer RL. User’s guide for the SCID-5-PD
(Structured Clinical Interview for DSM-5 Personality Disorder). Arlington: American
Psychiatric Association; 2015.
23. Kessler RC, Ustun TB. The World Mental Health (WMH) Survey Initiative Version of the
World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int
J Methods Psychiatr Res. 2004;13(2):93–121.
24. Wolraich ML, Feurer ID, Hannah JN, Baumgaertel A, Pinnock TY. Obtaining systematic
teacher reports of disruptive behavior disorders utilizing DSM-IV. J Abnorm Child Psychol.
1998;26(2):141–52.
25. Wolraich ML, Lambert W, Doffing MA, Bickman L, Simmons T, Worley K. Psychometric
properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population.
J Pediatr Psychol. 2003;28(8):559–68.
26. Conners CK. Conners comprehensive behavior rating scales manual. Multi-Health Systems:
Toronto; 2008.
27. Swanson JM, Kraemer HC, Hinshaw SP, Arnold LE, Conners CK, Abikoff HB, et al.
Clinical relevance of the primary findings of the MTA: success rates based on severity of
ADHD and ODD symptoms at the end of treatment. J Am Acad Child Adolesc Psychiatry.
2001;40(2):168–79.
28. Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, et al. The World Health
Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the
general population. Psychol Med. 2005;35(2):245–56.
29. Adler LA, Spencer T, Faraone SV, Kessler RC, Howes MJ, Biederman J, et al. Validity of
pilot Adult ADHD Self- Report Scale (ASRS) to rate adult ADHD symptoms. Ann Clin
Psychiatry. 2006;18(3):145–8.
30. Conners CK, Erhardt D, Sparrow E. CAARS: Conner’s Adult ADHD Rating Scales: Multi-­
Health Systems Incorporated (MHS); 1999.
31. Gallagher R, Blader J. The diagnosis and neuropsychological assessment of adult attention
deficit/hyperactivity disorder. Scientific study and practical guidelines. Ann N Y Acad Sci.
2001;931:148–71.
32. Brown TE. Brown Attention Deficit Disorder Scales (BADDS). 1st ed. San Antonio: The
Psychological Corporation; 1996.
33. Roth RM, Isquith PK, Gioia GA. BRIEF-A: Behavior Rating Inventory of Executive
Function—Adult Version: professional manual. Lutz: Psychological Assessment Resources;
2005.
34. Isquith PK, Roth RM, Gioia GA. Behavior Rating Inventory of Executive Function—Adult
Version (BRIEF-A) Interpretive Report. Lutz: Psychological Assessment Resources; 2006.
35. Edwards MC, Gardner ES, Chelonis JJ, Schulz EG, Flake RA, Diaz PF. Estimates of the
validity and utility of the Conners’ Continuous Performance Test in the assessment of
inattentive and/or hyperactive-impulsive behaviors in children. J Abnorm Child Psychol.
2007;35(3):393–404.
36. Epstein JN, Conners CK, Sitarenios G, Erhardt D. Continuous performance test results of
adults with attention deficit hyperactivity disorder. Clin Neuropsychol. 1998;12:155.
37. Epstein JN, Erkanli A, Conners CK, Klaric J, Costello JE, Angold A. Relations between
Continuous Performance Test performance measures and ADHD behaviors. J Abnorm Child
Psychol. 2003;31(5):543–54.
Another random document with
no related content on Scribd:
coriander seed. The breakfast before us was a most substantial one, there
being no lack either of welcome, which is the best of cheer, or of mutton, fish,
beer, coffee, milk, and stale black rye-bread. Be it remembered that this
breakfast was neither Icelandic, Danish, nor Scotch; but, exhibiting some of
the characteristics of all three, seemed marvellously adapted to our present
requirements in this distant habitat.
We stepped into the store, and saw exposed for sale hardware and soft goods
of all kinds. In a corner were standing lots of quart-bottles gaudily labelled
“essence of punch,” whatever that may be. Mr. Henderson showed me some
specimens of double refracting calc, or Iceland spar, which is obtained in the
neighbourhood. It only occurs in one place of the island, filling a fissure of
greenstone from two to three feet wide and twenty to twenty-five feet long, on
the north bank of the Reydarfiord, about a thousand feet above the sea level.
There, a cascade rushes over the rock, bringing down fragments of the spar
from time to time. The mass itself gets loosened, bit by bit, through the action
of frost on the moisture which enters edgeways between the laminae, wedging
them apart in the direction of the cleavage of the crystals. Transparent
specimens more than a few inches in size are rare and valuable. Mr. Henderson
presented me with a beautiful large semi-transparent chalcedony weighing 1 ℔
7 oz., and some pebbles.
His partner, Mr. Jacobson, an Icelander, also gave me a young raven to make a
pet of. It was this year’s bird and quite tame. I called it Odin; and, having got
hold of an old box, improvised a door from a few spars, that it might have a
sheltered place to roost in at night till it got to the end of its voyage.
I now wandered up the valley, for an hour or two, alone, and sat down on a
slope, on the right side of it, to look around me and rest. The river, near where
I sit, flashes down over a steep rock and forms a fine waterfall, the roaring of
which is echoed from the chimney-capped amphitheatre of hills opposite.
Beneath the fall, it flows peacefully along, runnelling and rippling on, to the
blue fiord, through the quiet green valley. White streamlets of water trickle
down the trap hill-sides, every forty or fifty yards; the whole producing a
continuous quiet murmur or undertone, not unlike that from the wings of an
innumerable swarm of gnats playing in the sunshine on a warm summer’s day,
but ever broken in upon by the clear liquid tinkle of the streamlets nearest us,
heard drip, dripping, with a clear metallic sound which might be compared to
the chirp of the grasshopper. This solitary glen, now lying bathed in light, is
fanned by the gentle breeze, fragrant with the smell of tedded hay, and richly
variegated with wild flowers—harebells, butter-cups, wild thyme, cotton-grass,
and forget-me-nots—a gathered bunch of which is now lying beside me on a
moss-cushioned rock. Quietly musing here on all, of strange or new, I have
seen since leaving home, and dwelling more particularly on the great kindness
I have received at all hands, I feel grateful to God, who has hitherto opened up
a way for me and given me friends amongst strangers wherever I chanced to
wander.
We saw specimens of surturbrand, which crops out on the top of a steep
mountain, at the mouth of the fiord, on the north side, and obtained a few
more geological specimens and plants.
After dinner, I strolled for a quarter of a mile up the valley with Mr.
Henderson and Dr. Mackinlay, to visit the farm behind the store. It consists of
a group of hovels, the walls are stone and turf, the gables wood, and the roofs
covered with green sod. The entrance is a dark muddy passage leading into a
ground-floor apartment as dark and muddy, where, in winter, cattle are kept.
The kitchen is a dirty, smoky, sooty hole, with fish hanging in it to smoke and
dry; a pot of seal-blubber stands steaming in a corner. The fire is raised on a
few stones above the floor, like a smithy-forge; while there is a hole in the roof
for the smoke. Picking our way through another long passage, dark and dirty,
we found a trap-ladder and ascended to a little garret, where I could only walk
erect in the very centre. The apartment was floored and fitted up with bunks
all round the sides and ends. In these box-beds, at least seven people—men,
women and children—sleep at night, and sometimes a few more have to be
accommodated. The little windows in the roof are not made to open, and no
regard whatever is paid to ventilation. Dr. Mackinlay prescribed for an old man
we found lying ill in this abominable fetid atmosphere, where his chances of
recovery were very slight. He was an old farm servant about whom nobody
seemed to care anything.
 FARM HOUSE, SEYDISFIORD.

In a little apartment shut off from this one, and in the gable portion of the
building which in this case constitutes the front of the house, an old woman at
the window sits spinning with the ancient distaff,[39] precisely as in the days of
Homer.
To amuse the farmer’s daughters I showed them my sketches, with which they
seemed much interested.
 SEYDISFIORD, LOOKING EAST TOWARDS THE SEA.

I understood part of their remarks, and could in some degree make myself
understood by them, with the few Danish and Icelandic words I kept picking
up. On receiving a little money and a few knick-knacks, they, all round, held
out their hands and shook mine very heartily. This, the Icelanders always do,
on receiving a present of anything however trifling.
After sketching the farm-house, I took two views of Mr. Henderson’s store;
one of them from a height behind, looking down towards the fiord, and the
other from the brink of it, looking up the valley. In the latter, a part of the
same farm-house appears, and thus indicates its exact position.[40] With the
assistance of these three sketches taken together, the reader will be enabled to
form some idea, of the appearance presented by this arm of the North Sea.
 SEYDISFIORD, BY FARÖE TO LEITH
We sailed from Seydisfiord at half-past six P.M. on Saturday night, direct for the
Faröe islands.
There is a singular cone-shaped mountain called Brimnæs Fjall at the mouth of
the fiord, showing masses of clay-rock alternating with and pushing up trap,
which is deposited in thin layers of perpendicular structure. Several pillars or
shafts are left standing singly on the very summit, and present a very curious
appearance, distinctly relieved against the amber light of the sky. At Dr.
Mackinlay’s request I made a sketch of it.

BRIMNÆS FJALL.

A vessel of Mr. Henderson’s, which had been given up as lost, now

unexpectedly came in sight, which necessitated Mr. Jacobson and a young
Iceland lad, who were en route to Copenhagen, to get on board her and return
to Seydisfiord to look after her cargo, evidently much to their disappointment.
The wild scenery of the coast, especially at Reydarfiord, was strikingly
picturesque.[41]
Mr. Murray, Professor Chadbourne, Mr. Henderson and I walked the deck till
a late or rather an early hour, and watched the fast receding mountain-ranges
of Iceland—pale lilac, mauve, or deep purple—and the distant horns, shading
through similar tints from rose to indigo, all distinctly seen athwart the golden
light of the horizon which for hours has been ebbing slowly and softly away,
but is now on the turn, and about to flow again.

Sabbath, August 7. The weather is fine; no land or sail in sight all day; whales
playing about the ship. Had many pleasant deck-walks and talks, and several
quiet hours, sitting perched on the stem, reading, or watching the prow, below,
cutting and cleaving through the clear green water like a knife.

Monday morning, August 8. We are sailing between two of the Faröe islands,
bright sunshine lighting up all the regularly terraced trap-rocks, caves, and
crevices of this singular group.
I have now got a pet to look after, and, without Shakspere’s authority for it, we
know that
“Young ravens must have food.”

The last thing I did last night was to shut Odin in his box, and the first thing
this morning to let him out again and give him the freedom of the ship. The
bird knows me, is pleased when I scratch his head, and confidingly runs
hopping to me for protection when the boys about the ship teaze him more
than he likes. His fellow traveller, a young Icelandic fox brought on board at
Reykjavik to be sent to the Marquis of Stafford, also runs about the ship
during the day. At first we had some misgivings on the subject; for
“Treason is but trusted like the fox—
Who ne’er so tame, so cherished, and locked up,
Will have a wild trick of his ancestors.”

However, these fears were soon dissipated; for Odin can hold his own, and
when the fox, approaching furtively, uses any liberty with his tail feathers, he
suddenly gets a peck from the bird’s great formidable beak, which he does not
seem much to relish. The salutary fear continues for a short time, is forgotten,
and again the dab comes as a reminder. We were often greatly amused,
watching their individual habits and droll ways, when the one intruded upon
the other. It was half play, half earnest, a sort of armed neutrality with a basis
of mutual respect.
On the west coast of Stromoe is the roofless ruin of the church of Kirkuboe.
It was begun in the twelfth century, but never finished. It is built of stone, has
five large windows and several small ones below; a little farm house or hut,
with red tiles on the roof, stands near it. What a strange lonely place for a
church! Thorshavn lies on the other—the east—side of the island. It is only
five miles distant as the crow flies, but as we have to sail round the south
point, and Stromoe is twenty-seven miles long, we do not reach it till near
noon.
On landing, Mr. Haycock accompanied me to call for Miss Löbner, who has
been poorly ever since her sea voyage. Her mother presented wine, cake,
coffee &c., and was most hospitable. None of us being able to speak Faröese,
at first we felt a little awkward; but a brother of the old lady’s who speaks
English soon came to the rescue and acted as interpreter. With justifiable
pride, they again showed us their flower and kitchen garden. I got the whale-
knives, caps, shoes, gloves &c., which had been made or procured for me
during my absence in Iceland. Ere leaving, Miss Löbner appeared to say adieu!
and insisted on my accepting several other specimens of Faröese workmanship
as remembrances of Thorshavn. No people could have been kinder.
Again, wandering about, we explored the town, looked at the church, stepped
into the stores, passed the governor’s garden, and wandered a mile or two in
that direction in order to obtain a view, and get quit of the fishy smells which
superabound in Thorshavn.
On our return we called for Mr. Müller, who presented me with a copy of the
gospel of St. Matthew in Danish and Faröese, arranged in parallel columns. I
understood him to say that this was the only book ever printed in the Faröese
dialect, and that it is now out of print and very rare. It bears the date of 1823.
Here we saw an old man 76 years of age, an Icelander who has been in Faröe
for the last 40 years. He had spent several years in England, and told me that,
in 1815, he saw our regiments land at Liverpool after the battle of Waterloo.
He speaks English fluently.
A Thames fishing smack, and a sloop from Lerwick, are lying in the bay.
Piping and dancing goes merrily on, on board the latter, relieved by intervals
of music alone. In one of these, we heard “The Yellow Hair’d Laddie,”
rendered with considerable taste, although, doubtless, several “improvements
and additions” were made on the original score.
We took some Faröese boatmen into the saloon of the steamer, and I shall not
soon forget the look of wonder and utter astonishment pourtrayed on their
countenances, as they gazed on the mirrors and everything around, or were
shown things with which they were not familiar and heard their uses explained.
They were greatly pleased with my life-belt. Dr. Mackinlay showed them a
multiplying-glass, and, as it was handed from one to another—each man first
making the discovery of what had so inexplicably excited the wonder of the
last looker—the queer exclamations of amazement accompanied by inimitable
pantomimic gestures reached their culminating point, and were irresistibly
droll.

NAALSÖE—FARÖE.

The weather is all we could desire. The sailors are singing some curious Danish
songs, with the time well marked, as they heave the anchor; and at 20 minutes
past 6 o’clock P.M. we are steaming out of the bay. The evening is lovely, and
the Thermometer, on the deck, stands at 68°. Thorshavn soon disappears, and
we leave the Faröe islands astern, relieved against an amber sky, Dimon being
the most striking and conspicuous of the group. A few stars shone overhead,
and I walked the deck till midnight.
 ENTRANCE TO THE SOUND LEADING TO THORSHAVN.

Tuesday, August 9. At breakfast, tasted a whale-steak which Miss Löbner had

yesterday sent on board for me, with particular instructions to the stewardess
to have it properly cooked. The flesh looked and tasted like dry tough beef,
with a slight flavour of venison. The blubber, however was too strong for any
of us to do more than merely satisfy—not gratify—our curiosity.
The day was lovely. Professor Chadbourne invited me to visit and spend a
month with him during his holiday. Indeed, cordial, pressing invitations, all
round, were the order of the day. As fellow-travellers we had been happy
together, and felt sorry at the near prospect of our little party being broken up
and scattered; for several valued friendships had been formed.
Between three and four o’clock in the afternoon, the thermometer indicated
98° in the sun and 75° in the shade. Dr. Mackinlay showed me an old Danish
dollar he had got, in change, at Reykjavik; it bore the date of A.D. 1619, the year
of the landing of the Pilgrim Fathers from the May Flower. Part of the day was
spent in writing out these pages from my diary. In the evening we saw, far to
our left, faint and dim on the horizon line, the north-west islands of Shetland;
and by a quarter to 8 o’clock P.M. were sailing twenty miles to the west of Fair
Isle, which lies between Orkney and Shetland. Both groups are in sight. We
have not seen a sail since we left Faröe, and now, what we at first fancied to be
one, off the north end of the Orkneys, turns out to be a light-house, rising
apparently from the sea, but in reality from low lying land which is yet below
the horizon.
The sunset to-night is gorgeous; cavernous recesses opening through a dense
purple cloud-bank into glowing regions of fire; while broad flashing gleams ray
out on every side athwart the sky, as if from furnace-mouths. Then we have
moonlight on a sea smooth as glass, and not even a ripple to be seen. The
Orkney light-house, now gleaming like a setting star, is left far astern. The
phosphoresence along the vessel’s side and in her wake is most brilliant; while,
seething, electric-like, from the screw, it rivals the “churned fire-froth” of the
demon steed. The moon, half-hid, is at times deep crimson and again bright
yellow. Many falling stars are shooting “madly from their spheres;” not that
our music lured them, although, “on such a night” of nights, when all is
harmonious, we cannot but sing. Mr. Murray gives us “Home, sweet home”
and “The last rose of summer,” and ere retiring at midnight, all of us join
together in singing the “Spanish Chant.”

Wednesday morning, August 10. We are off Inverness; wind a-head and rising.
Professor Chadbourne to-day gave me an oak-leaf which he plucked from the
tree, at Upsala, planted by Linnæus with his own hands. Wrote as long as the
heaving of the ship would admit of it, then arranged botanical specimens and
read Wordsworth. The wind is blowing so fresh, off Peterhead, that, with full
steam, we are not making above one and a half knots; and at times can scarcely
keep any way on. Passed the Bell-Rock; the sea still rising. Went to bed at 11
o’clock P.M.; vessel pitching a good deal.

Thursday morning, August 11. Rose at four o’clock and was on deck ere the
Arcturus dropt anchor in Leith Roads. But as we cannot get our traps on shore
till the custom-house officer comes at nine o’clock to overhaul them, we
remain and breakfast on board. The examination made, at half-past ten o’clock
A.M., we landed by a tug steamer, and made for our respective railway stations,
each, on parting, bidding the other “a bright adieu!” in the hope that it might
only be for “a brief absence!” “Odin” was in good feather: his owner sun-
bronzed and strong.
At length, comfortably ensconsed in the fast express, I lay back in the corner
of a compartment, closed my eyes and resigned myself to see pleasant pictures
and dream waking dreams—of snow jökuls, volcanoes, glaciers, and ice-fields;
of geysers, mud-cauldrons, and sulphur-pits; of lava plains, black, wierd and
blasted, or dreary wastes of ice; of deep rapid rivers, flashing waterfalls, leaping
torrents; of frightful chasms, rugged cliffs, and precipitous mountains
mirrored in deep blue fiords; of pathless stony deserts, enlivened at times with
oasis-like spots of tender green herbage and bright coloured flowers; of wild
break-neck rides, over bare rocks, among slabs and lava-blocks of all shapes
and sizes and lying in every conceivable direction; through volcanic sands and
scoriæ; by red and black vetrified craters, or across dangerous fords; of
multifarious scamperings too, and mud-plashings over hill and dale; or wild
rides down rocky steeps, not on a phantom steed, but on a sure-footed Iceland
pony; of pleasant companionship by the way; of cordial welcome and great
kindness received, in quiet homesteads, and at all hands from the people,
wherever we went; then again of Frost contending with Fire, and of all the
varied and marvellous phenomena of Iceland, that singularly interesting island
in the lone North Sea.

STROMOE—FARÖE.
APPENDIX.
 I.

ICELANDIC STORIES AND FAIRY TALES

TRANSLATED INTO ENGLISH BY THE REV. OLAF PÁLSSON, DEAN
AND RECTOR OF REYKJAVIK CATHEDRAL. REVISED AND
EDITED BY DAVID MACKINLAY AND ANDREW JAMES
SYMINGTON.

STORIES OF SÆMUNDUR FRODI, CALLED THE

LEARNED.[42]

I. THE DARK SCHOOL.

Long, long ago, when Trolls and Giants lived among men, there was a famous
school where curious youths were taught the mysteries of witchcraft. France
and Germany both claim the honour of it, but no one knows where it really
was.
It was kept in a dismal cavern, deep underground, into which no ray of
sunlight ever entered. Here, the scholars had to stay no less than seven winters;
for it took them all that time to complete their studies. They never saw their
teacher from one year’s end to another. Every morning a grey grizzly hand, all
covered with hair, pushed itself through the cavern wall and gave to each one
his lesson book. These books were written all over with letters of fire, and
could be read with ease, even in the dark. The lessons over, the same grizzly
hand again appeared to take away the books and bring in the scholars’ dinner.
At the close of winter, the scholars who had then got through their seven years
apprenticeship were dismissed. The great iron door was opened, and the
master stood watching those who went out; for he had stipulated that the
scholar who walked hindmost, in passing through, was to be seized by him and
kept as a thrall. But who was this strange school-master? Why, Old Nick
himself. No wonder, then, that each of the scholars struggled hard to be first
in passing the fatal threshold.
Once on a time, there were three Icelanders at the dark school; Sæmund Frodi,
afterwards parish priest at Oddi, Kalfur Arnason, and Halfdan Eldjarnsson,
afterwards parish priest at Fell, in Slettuhlid. They were all dismissed at the
same time. Sæmund, to the great delight of his companions, offered to walk
hindmost in going out of school, so he dressed himself in a long loose cloak,
which he took care to leave unbuttoned, and bidding good bye to school-
fellows left behind, prepared to follow his countrymen. Just as he was putting
his feet on the first step of the stair which led up from the school door, Old
Nick, who was watching hard by, made a clutch at the cloak and called out,
“Sæmund Frodi, pass not the door,
Thou art my thrall for evermore.”

And now the great iron door began to turn on its hinges; but, before Old Nick
had time to slam it too, Sæmund slipt his arms out of the sleeves of his cloak,
and sprung forward out of the grasp of his enemy.
In doing so, the door struck him a heavy blow on the heel, which gave him a
good deal of pain, when he said,
“The door hath swung too near the heel,
But better sore foot than serve the Deil.”

And so Sæmund outwitted Old Nick, and got away from the dark school along
with his two friends. Since then, it has become a common saying in Iceland,
when a person has had a narrow escape from danger, that “the door swung
too near his heels.”[43]

II. SÆMUND GETS THE LIVING OF ODDI.

At the time Sæmund, Kalfur, and Halfdan came out of the dark school, there
was no priest at Oddi, for the old priest had just died. All three of them would
fain have the living, and so each went to the king to ask it for himself. The
king knew his men; and so he sent them all away with the same answer, that
whoever reached Oddi first, should be made priest of that place.
Thereupon Sæmund summoned Old Nick and said to him, “Now, I’ll make a
bargain with you, if you swim with me on your back across to Iceland, and
land me there without wetting my coat-tail, I’ll be your servant as long as I
live.” Old Nick was highly pleased with the offer and agreed at once. So, in less
than no time, he changed himself into a seal, and left Norway with Sæmund on
his back.
Sæmund took care to have his prayer book with him, and read bits out of it
every now and then while on the way. As soon as they got close to the shores
of Iceland, which they did in less time than you would think, he closed the
book and suddenly struck the seal such a heavy blow on the neck with it that
the animal went down all at once into deep water. Sæmund, now left to
himself, struck out for the shore and got easily to land. In this way Old Nick
lost his bargain, and Sæmund got the living of Oddi.

III. THE GOBLIN AND THE COWHERD.

When Sæmund was priest of Oddi, he once had a cowherd—a good servant
withal, but greatly addicted to swearing. Sæmund often reproved him for this,
but all his reproofs were of no avail. At last he told him, he really ought to
leave off his bad habits, for Old Nick and his servants lived upon people’s
curses and wicked words. “Say you so?” said the cowherd, “if I knew for
certain that Old Nick would lose his meals by it, I would never say a bad word
more.” So he made up his mind to mend his ways.
“I’ll soon see whether you are in earnest or not,” said Sæmund, and so, he
forthwith lodged a goblin in the cowhouse. The cowherd did not like his
guest, and no wonder: for he was up to every kind of mischief, and almost
worried the life out of him with his wicked pranks. The poor cowherd bore up
bravely for a time, and never let slip an oath or angry word. The goblin got
leaner day by day, to the intense delight of the cowherd, who hoped, bye and
bye, to see an end of him.
One morning, on opening the byre door, the poor cowherd found every thing
turned topsy-turvy. The milk pails and stools were broken in pieces and
scattered about the floor; and the whole of the cows—and there were many of
them—tied tail to tail, were straggling about without halters, and goring each
other. It needed but half an eye to see who had done the mischief. So the
cowherd in a rage turned round to the goblin who, shrunk and haggard, lay
crouched up in a corner of a stall, the very picture of wretchedness, and
poured forth such a volley of furious curses as would have overwhelmed any
human being in the same plight. The goblin all at once began to revive; his
skin no longer shrivelled looked smooth and plump; his eye brightened up, and
the stream of life again flowed joyously through his veins.
“O, oh!” said the cowherd, as he suddenly checked himself, when he saw the
wonderful effect his swearing had on the goblin, “Now I know for certain that
Sæmund was right.” And from that day forward he was never known to utter
an oath. As for the goblin, he soon pined away again and has long since been
beyond troubling anybody. May you and I, and all who hear this story, strive to
follow the good example of Sæmund’s cowherd!

IV. OLD NICK MADE HIMSELF AS LITTLE AS HE WAS ABLE.

Sæmund one day asked Old Nick how little he could make himself. “Why,”
replied he, “as for that I could make myself as small as the smallest midge.”
Thereupon Sæmund bored a tiny hole in the door post, and asked him to
make good his boast by walking into it. This he at once did; but no sooner was
he in, than Sæmund stopped the hole with a little plug of wood, and made all
fast.
Old Nick cursed his folly, cried, and begged for mercy; but Sæmund would not
take out the stopper till he promised to become his servant and do all that he
was told. This was the reason why Sæmund always had it in his power to
employ Old Nick in whatever business he liked.

V. THE FLY.

As might be expected, Old Nick always harboured a great ill will against
Sæmund: for he could not help feeling how much he was in Sæmund’s power.
He therefore tried to revenge himself on various occasions; but all his tricks
failed, for Sæmund was too sharp for him.
Once, he put on the shape of a little fly, and hid himself—so he thought, at
least—under the film that had gathered on the priest’s milk jug, hoping that
Sæmund would swallow him unawares, and so lose his life. But Sæmund had
all his eyes about him; so instead of swallowing the fly he wrapped it up in the
film, covered the whole with a bladder, and laid the package on the altar.
There, the fly was obliged to remain till after the service, when Sæmund
opened the package and gave Old Nick his liberty. It is told, as a truth, that old
Nick never found himself in a worse case than when lying on the altar before
Sæmund.
 VI. THE GOBLIN’S WHISTLE.

Sæmund had a whistle of such wonderful power, that, as often as he blew it,
one or more goblins appeared before him, ready to do his bidding.[44] One day,
on getting up, he happened to leave the whistle under his pillow, and forgot all
about it till the afternoon when the housemaid was going to make his bed. He
charged her, if she found anything unusual about the bed, she was on no
account to touch it, or move it from its place. But he might have saved himself
the trouble of speaking; for, as soon as the girl saw the whistle, she took it up
in her hand, and looked at it on every side. Not satisfied with much handling
it, she put it to her mouth and blew it lustily. The sound of the blast had not
died away before a goblin stood before her, saying, “what will you have me to
do?” The girl was not a little startled, but had the presence of mind to conceal
her surprise.
It so happened that the hides of ten sheep, that had been killed that day, were
lying on the ground in front of the parsonage. Recollecting this, the girl replied
to the goblin, “Go and count all the hairs that are on the ten hides outside,
and, if you finish your task before I get this bed made, I’ll consent to marry
you.” The goblin thought that a task worth undertaking for such a prize; and
hurrying out, fell to counting the hairs with all his might. The girl who did not
like the idea of being the wife of a goblin, lost no time, you may be sure, in
getting through with her work; and it was well she bestirred herself; for, by the
time the bed was made, the goblin had almost finished his task. Only a few
hairs of the last hide remained uncounted, but they were enough to make him
lose his bargain. When Sæmund afterwards learned how prudently the girl had
got out of her scrape, he was very well pleased.

ICELANDIC FAIRY TALES.

BIARNI SVEINSSON AND HIS SISTER SALVÖR.[45]

Once on a time, a worthy couple, Sveinn and his wife, occupied a farm, on the
shores of the beautiful Skagafiord, in the north country. They were in easy
circumstances and were blessed with two fine children, a son and daughter,
who were the joy of their hearts. Biarni and his sister Salvör—for these were
the names of their children—were twins and greatly attached to each other.
In the spring of the year,[46] about St. John’s day, when these two had reached
the age of twenty, the people of Skagafiord were arranging a party to make a
journey to the mountains of the interior, to gather Iceland-moss for making
porridge. Sveinn promised to let his son go with the party. As soon as Salvör
knew that, she felt a great desire to go too; and so she went to her parents to
ask their consent. This was not so easily got, as they did not wish to part with
both their children at once; and besides, they knew she was ill fitted to bear the
hardships and fatigues of mountain travelling. But she fretted so much at the
thought of being left behind, that, at last, they consented to let her go.
The night before the moss-gatherers were to leave, Sveinn the farmer dreamed
that he had two beautiful white birds, of which he was very fond, and that all
at once, to his great grief, the hen-bird disappeared and could nowhere be
found. On awaking in the morning, he could not help thinking that his dream
betokened no good to his darling Salvör, so he called her to him, and after
telling her his dream, he said to her, “Salvör dear! I cannot bear to part with
you, you must stay at home with your mother and me, for I would never
forgive myself if any ill befel you by the way.” Salvör who had been in great
glee at the prospect of riding, day after day, up the romantic valleys to the
south of Skagafiord, and there tenting out amidst the mountains, was neither
to hold nor to bind, when she found that, after all, she would have to stay at
home; she wept with vexation and distressed herself so much that her father
could not bear it, and again gave an unwilling consent to let her go. So she
accompanied her brother and the rest of the party to the mountains.
The first day after getting there, she gathered Iceland-moss with the others,
but during the night she fell suddenly ill and was unable to leave her tent on
the following day. Biarni stayed with her, and did all that a brother could do to
help and comfort her. For three whole days he was her companion, but, on the
fourth day, he left her for a time in charge of a friend, while he himself joined
the moss-gatherers. After partly filling his bag, he sat himself down by a large
stone, and, resting his head on his hand, brooded over his sister’s unhappy
fate; he feared she was going to die among the mountains.
By and by he heard a great tramping of horses, and, on looking about, he saw
two men riding towards him at a quick pace. One of them wore red coloured
clothes, and had a red horse; the other who was younger, was dressed in black,
and was mounted on a black horse. On reaching the place where Biarni was
sitting, they dismounted and saluted him by name.
“What ails you Biarni,” said the elder of the two strangers. For a time Biarni
answered not a word, but on being pressed to do so, he opened up his heart to
them and told all about his sister’s illness.
“My companions are going to return home, but I must stay to watch over
Salvör; and who knows how soon she may die in my arms.”
“You are in a hard case Biarni,” said the other, “and I am sorry for you, but
won’t you leave your sister with me, and I will take good care of her.”
“No, no,” said Biarni, “that I dare not do, for I know neither who you are, nor
where you come from. But will you tell me where your home is?”
“That’s no business of yours,” said the other, rather gruffly, and then, taking
from his pocket a silver-gilt box set with precious stones, added, “Won’t you
sell me your sister for this box.”
“No,” said Biarni, “nor for a thousand like it. I would not give her to you for
any money.”
“Well! well! there is no help for it, you will at all events accept this box, as a
token that you have met with men among the mountains.”
Biarni took the offered gift with pleasure, and thanked the giver. The two men
then bade him farewell and rode away, while he returned to the tent. Next
morning his companions went away home, leaving him alone with his sister.
Though she was now a little better, he dared not sleep, for he was afraid lest
the strangers should come and steal her away. But, after watching a whole day
and night, he felt overcome with fatigue; so he lay down, and folding his arms
round her waist to protect her, fell into a sound sleep. But, when he awoke, his
sister was gone, and was nowhere to be found. He spent a whole day
sorrowfully wandering from spot to spot, looking and calling for her, but it
was all in vain. He then turned his back on the mountains, and with a heavy
heart went home, and told his parents what had happened.
“Woe is me,” said Sveinn, “what I feared most has come to pass, but God’s
will be done!”
There was great grief in Skagafiord when the news spread from farm to farm;
for Salvör, with all her way-wardness, was a promising girl, and was every
body’s favourite. A party of young men returned to the mountains to look for
her, but nowhere was the least trace of her to be found.
And now ten years had passed away. By this time Biarni was married and
settled on a farm, not far from his father’s. During autumn all his sheep went
amissing, and his shepherd could not discover what had become of them
though he searched diligently for them three whole days. On learning this,
Biarni bid his wife provide him with a week’s supply of food, and an extra pair
of shoes; “for,” said he, “I shall go to the mountains myself to look for the
sheep.” His parents, who were still alive, urged him to stay at home; for they
feared that, if he went to the mountains, they might never see his face again.
“I must go,” said he to them, “I cannot afford to lose the sheep. But be of
good heart, and do not begin to weary for me till the week is over.”
He then went away on foot, and did not leave off walking for three days. At
the end of that time he came to a cavern, where he turned in and lay down to
sleep. On waking, he could not see a yard before him; for a thick fog which
rested on the ground. He continued his journey, but soon lost his way.
Towards evening the fog cleared off, and he found himself in a spacious valley,
not far from a large well built farm house. It was the hay season, so that all the
people of the farm were busy in the meadow. On getting near the house, he
noticed, in particular, two women and a girl who were tedding the hay. “God’s
peace be with you,” said he, on reaching the spot; and then, telling them of his
mishaps, he asked permission to stay all night under their roof. They gave him
a hearty welcome, and the girl went with him to the house. She was of more
genteel appearance than the rest—young and handsome—and, as Biarni
thought, bore some resemblance to his long lost but well remembered sister.
This unexpected circumstance renewed his old griefs, but he did what he could
to seem cheerful before his young hostess. She led him through several
apartments to a large well furnished room, where everything was neat and tidy.
Here, she drew in a chair, and kindly asked him to sit down and rest, while she
brought in supper. He had not long to wait; for she soon placed upon the table
a plentiful supply of meat and wine.
After supper, she showed him to the little room where he was to sleep for the
night; she then took away his wet clothes, wished him a kind good night, and
left the room.
As Biarni lay in bed, he fell a-wondering where he was, and how the sight of
the girl should have so waked up the sad memories of the past. He fell asleep
thinking of these things, but was soon awakened by the sound of singing in a
room over his head. It was the family at evening worship, as is the custom of
the country. He heard both men and women singing, but one voice sounded