Attention-Deficit / Hyperactivity Disorder (ADHD) in Children

ADHD symptoms persist for kids despite treatment

Attention-Deficit / Hyperactivity Disorder (ADHD) in Children | Johns Hopkins Medicine

Nine 10 young children with moderate to severe attention-deficit hyperactivity disorder continue to experience serious, often severe symptoms and impairment long after their original diagnoses and, in many cases, despite treatment, according to a federally funded multicenter study led by investigators at Johns Hopkins Children's Center.

The study, published online Feb. 11 in the Journal of the American Academy of Child & Adolescent Psychiatry, is the largest long-term analysis to date of preschoolers with ADHD, the investigators say, and sheds much-needed light on the natural course of a condition that is being diagnosed at an increasingly earlier age.

“ADHD is becoming a more common diagnosis in early childhood, so understanding how the disorder progresses in this age group is critical,” says lead investigator Mark Riddle, a pediatric psychiatrist at Johns Hopkins Children's Center. “We found that ADHD in preschoolers is a chronic and rather persistent condition, one that requires better long-term behavioral and pharmacological treatments than we currently have.”

The study shows that nearly 90 percent of the 186 youngsters followed continued to struggle with ADHD symptoms six years after diagnosis. Children taking ADHD medication had just as severe symptoms as those who were medication-free, the study found.

Children with ADHD, ages 3 to 5, were enrolled in the study and treated for several months, after which they were referred to community pediatricians for ongoing care.

Over the next six years, the researchers used detailed reports from parents and teachers to track the children's behavior and school performance, and the frequency and severity of three of ADHD's hallmark symptoms: inattention, hyperactivity, and impulsivity.

The children also had full diagnostic workups by the study's clinicians at the beginning of, halfway through, and at the end of the research. 

Symptom severity scores did not differ significantly between the more than two-thirds of children on medication and those off medication, the study showed. Specifically, 62 percent of children taking anti-ADHD drugs had clinically significant hyperactivity and impulsivity, compared with 58 percent of those not taking medicines.

And 65 percent of children on medication had clinically significant inattention, compared with 62 percent of their medication-free counterparts.

The investigators caution that it remains unclear whether the lack of medication effectiveness was due to suboptimal drug choice or dosage, poor adherence, medication ineffectiveness per se, or some other reason.

“Our study was not designed to answer these questions, but whatever the reason may be, it is worrisome that children with ADHD, even when treated with medication, continue to experience symptoms, and what we need to find out is why that is and how we can do better,” Riddle says.

Children who had oppositional defiant disorder or conduct disorder in addition to ADHD were 30 percent more ly to experience persistent ADHD symptoms six years after diagnosis, compared with children whose sole diagnosis was ADHD.

ADHD is considered a neurobehavioral condition and is marked by inability to concentrate, restlessness, hyperactivity, and impulsive behavior.

It can have profound and long-lasting effects on a child's intellectual and emotional development, Riddle says. It can impair learning, academic performance, peer and family relationships, and even physical safety.

Past research has found that children with ADHD are at higher risk for injuries and hospitalizations.

More than 7 percent of children in the United States are currently being treated for ADHD, the investigators say. The annual economic burden of the condition is estimated to be between $36 billion and $52 billion, according to researchers.

Other Johns Hopkins investigators on the research were Elizabeth Kastelic and Gayane Yenokyan.

The other institutions involved in the research were Columbia University Medical Center; Duke University; the Nathan Kline Institute; University of California, Irvine; and University of California, Los Angeles. The research was funded by the National Institute of Mental Health.

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adhd, johns hopkins children's center

Source: https://hub.jhu.edu/gazette/2013/march/news-adhd-johns-hopkins-childrens-center-research/

ADHD symptoms persist for most young children despite treatment

Attention-Deficit / Hyperactivity Disorder (ADHD) in Children | Johns Hopkins Medicine

Nine 10 young children with moderate to severe attention-deficit hyperactivity disorder (ADHD) continue to experience serious, often severe symptoms and impairment long after their original diagnoses and, in many cases, despite treatment, according to a federally funded multi-center study led by investigators at Johns Hopkins Children's Center.

The study, published online Feb. 11 in the Journal of the American Academy of Child & Adolescent Psychiatry, is the largest long-term analysis to date of preschoolers with ADHD, the investigators say, and sheds much-needed light on the natural course of a condition that is being diagnosed at an increasingly earlier age.

“ADHD is becoming a more common diagnosis in early childhood, so understanding how the disorder progresses in this age group is critical,” says lead investigator Mark Riddle, M.D.

, a pediatric psychiatrist at Johns Hopkins Children's Center.

“We found that ADHD in preschoolers is a chronic and rather persistent condition, one that requires better long-term behavioral and pharmacological treatments than we currently have.”

The study shows that nearly 90 percent of the 186 youngsters followed continued to struggle with ADHD symptoms six years after diagnosis. Children taking ADHD medication had just as severe symptoms as those who were medication-free, the study found.

Children with ADHD, ages 3 to 5, were enrolled in the study, treated for several months, after which they were referred to community pediatricians for ongoing care.

Over the next six years, the researchers used detailed reports from parents and teachers to track the children's behavior, school performance and the frequency and severity of three of ADHD's hallmark symptoms — inattention, hyperactivity and impulsivity.

The children also had full diagnostic workups by the study's clinicians at the beginning, halfway through and at the end of the research.

Symptom severity scores did not differ significantly between the more than two-thirds of children on medication and those off medication, the study showed. Specifically, 62 percent of children taking anti-ADHD drugs had clinically significant hyperactivity and impulsivity, compared with 58 percent of those not taking medicines.

And 65 percent of children on medication had clinically significant inattention, compared with 62 percent of their medication-free counterparts.

The investigators caution that it remains unclear whether the lack of medication effectiveness was due to suboptimal drug choice or dosage, poor adherence, medication ineffectiveness per se or some other reason.

“Our study was not designed to answer these questions, but whatever the reason may be, it is worrisome that children with ADHD, even when treated with medication, continue to experience symptoms, and what we need to find out is why that is and how we can do better,” Riddle says.

Children who had oppositional defiant disorder or conduct disorder in addition to ADHD were 30 percent more ly to experience persistent ADHD symptoms six years after diagnosis, compared with children whose sole diagnosis was ADHD.

ADHD is considered a neurobehavioral condition and is marked by inability to concentrate, restlessness, hyperactivity and impulsive behavior.

It can have profound and long-lasting effects on a child's intellectual and emotional development, Riddle says. It can impair learning, academic performance, peer and family relationships and even physical safety.

Past research has found that children with ADHD are at higher risk for injuries and hospitalizations.

More than 7 percent of U.S. children are currently treated for ADHD, the investigators say. The annual economic burden of the condition is estimated to be between $36 billion and $52 billion, according to researchers.

Other Johns Hopkins investigators on the research included Elizabeth Kastelic, M.D., and Gayane Yenokyan, Ph.D.

The other institutions involved in the research were Columbia University Medical Center, Duke University, the Nathan Kline Institute, University of California — Irvine and University of California — Los Angeles.

The research was funded by the National Institute of Mental Health under grant numbers: U01 MH60642 (Johns Hopkins), U01MH60848 (Duke University Medical Center), U01MH60943 (New York University Child Study Center), U01MH60903 (Columbia University), U01 MH60833 (University of California-Irvine) and U01H60900 (University of California — Los Angeles).

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Materials provided by Johns Hopkins Medicine. Note: Content may be edited for style and length.

Journal Reference:

  1. Mark A. Riddle, Kseniya Yershova, Deborah Lazzaretto, Natalya Paykina, Gayane Yenokyan, Laurence Greenhill, Howard Abikoff, Benedetto Vitiello, Tim Wigal, James T. McCracken, Scott H. Kollins, Desiree W. Murray, Sharon Wigal, Elizabeth Kastelic, James J. McGough, Susan dosReis, Audrey Bauzó-Rosario, Annamarie Stehli, Kelly Posner. The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-Year Follow-Up. Journal of the American Academy of Child & Adolescent Psychiatry, 2013; DOI: 10.1016/j.jaac.2012.12.007

Source: https://www.sciencedaily.com/releases/2013/02/130211162112.htm

Attention-Deficit / Hyperactivity Disorder (ADHD) in Children

Attention-Deficit / Hyperactivity Disorder (ADHD) in Children | Johns Hopkins Medicine

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ADHD, also called attention-deficit disorder, is a behavior disorder, usually first diagnosed in childhood, that is characterized by inattention, impulsivity, and, in some cases, hyperactivity. These symptoms usually occur together; however, one may occur without the other(s).

The symptoms of hyperactivity, when present, are almost always apparent by the age of 7 and may be present in very young preschoolers. Inattention or attention-deficit may not be evident until a child faces the expectations of elementary school.

What are the different types of ADHD?

Three major types of ADHD include the following:

  • ADHD, combined type. This, the most common type of ADHD, is characterized by impulsive and hyperactive behaviors as well as inattention and distractibility.
  • ADHD, impulsive/hyperactive type. This, the least common type of ADHD, is characterized by impulsive and hyperactive behaviors without inattention and distractibility.
  • ADHD, inattentive and distractible type. This type of ADHD is characterized predominately by inattention and distractibility without hyperactivity.

What causes attention-deficit/hyperactivity disorder?

ADHD is one of the most researched areas in child and adolescent mental health. However, the precise cause of the disorder is still unknown. Available evidence suggests that ADHD is genetic. It is a brain-based biological disorder.

Low levels of dopamine (a brain chemical), which is a neurotransmitter (a type of brain chemical), are found in children with ADHD.

Brain imaging studies using PET scanners (positron emission tomography; a form of brain imaging that makes it possible to observe the human brain at work) show that brain metabolism in children with ADHD is lower in the areas of the brain that control attention, social judgment, and movement.

Who is affected by attention-deficit/hyperactivity disorder?

Estimates suggest that about 4% to 12% of children have ADHD. Boys are 2 to 3 times more ly to have ADHD of the hyperactive or combined type than girls.

Many parents of children with ADHD experienced symptoms of ADHD when they were younger. ADHD is commonly found in brothers and sisters within the same family. Most families seek help when their child's symptoms begin to interfere with learning and adjustment to the expectations of school and age-appropriate activities.

What are the symptoms of attention-deficit/hyperactivity disorder?

The following are the most common symptoms of ADHD. However, each child may experience symptoms differently. The 3 categories of symptoms of ADHD include the following:

  • Inattention:
    • Short attention span for age (difficulty sustaining attention)
    • Difficulty listening to others
    • Difficulty attending to details
    • Easily distracted
    • Forgetfulness
    • Poor organizational skills for age
    • Poor study skills for age
  • Impulsivity:

    • Often interrupts others
    • Has difficulty waiting for his or her turn in school and/or social games
    • Tends to blurt out answers instead of waiting to be called upon
    • Takes frequent risks, and often without thinking before acting
  • Hyperactivity:

    • Seems to be in constant motion; runs or climbs, at times with no apparent goal except motion
    • Has difficulty remaining in his/her seat even when it is expected
    • Fidgets with hands or squirms when in his or her seat; fidgeting excessively
    • Talks excessively
    • Has difficulty engaging in quiet activities
    • Loses or forgets things repeatedly and often
    • Inability to stay on task; shifts from one task to another without bringing any to completion

The symptoms of ADHD may resemble other medical conditions or behavior problems. Keep in mind that many of these symptoms may occur in children and teens who do not have ADHD. A key element in diagnosis is that the symptoms must significantly impair adaptive functioning in both home and school environments. Always consult your child's doctor for a diagnosis.

How is attention-deficit/hyperactivity disorder diagnosed?

ADHD is the most commonly diagnosed behavior disorder of childhood. A pediatrician, child psychiatrist, or a qualified mental health professional usually identifies ADHD in children.

A detailed history of the child's behavior from parents and teachers, observations of the child's behavior, and psychoeducational testing contribute to making the diagnosis of ADHD. Because ADHD is a group of symptoms, diagnosis depends on evaluating results from several different sources, including physical, neurological, and psychological testing.

Certain tests may be used to rule out other conditions, and some may be used to test intelligence and certain skill sets. Consult your child's doctor for more information.

Treatment for attention-deficit/hyperactivity disorder

Specific treatment for attention-deficit/hyperactivity disorder will be determined by your child's doctor :

  • Your child's age, overall health, and medical history
  • Extent of your child's symptoms
  • Your child's tolerance for specific medications or therapies
  • Expectations for the course of the condition
  • Your opinion or preference

Major components of treatment for children with ADHD include parental support and education in behavioral training, appropriate school placement, and medication. Treatment with a psychostimulant is highly effective in most children with ADHD.

Treatment may include:

  • Psychostimulant medications. These medications are used for their ability to balance chemicals in the brain that prohibit the child from maintaining attention and controlling impulses. They help “stimulate” or help the brain to focus and may be used to reduce the major characteristics of ADHD. Medications that are commonly used to treat ADHD include the following:
    • Methylphenidate (Ritalin, Metadate, Concerta, Methylin)
    • Dextroamphetamine (Dexedrine, Dextrostat)
    • A mixture of amphetamine salts (Adderall)
    • Atomoxetine (Strattera). A nonstimulant SNRI (selective serotonin norepinephrine reuptake inhibitor) medication with benefits for related mood symptoms. 
    • Lisdexamfetamine (Vyvanse)

    Psychostimulants have been used to treat childhood behavior disorders since the 1930s and have been widely studied. Traditional immediate release stimulants take effect in the body quickly, work for 1 to 4 hours, and then are eliminated from the body.

    Many long-acting stimulant medications are also available, lasting 8 to 9 hours, and requiring 1 daily dosing. Doses of stimulant medications need to be timed to match the child's school schedule to help the child pay attention for a longer period of time and improve classroom performance.

    The common side effects of stimulants may include, but are not limited to, the following:

    • Insomnia
    • Decreased appetite
    • Stomach aches
    • Headaches
    • Jitteriness
    • Rebound activation (when the effect of the stimulant wears off, hyperactive and impulsive behaviors may increase for a short period of time)

    Most side effects of stimulant use are mild, decrease with regular use, and respond to dose changes. Always discuss potential side effects with your child's doctor.

    Antidepressant medications may also be administered for children and adolescents with ADHD to help improve attention while decreasing aggression, anxiety, and/or depression.

  • Psychosocial treatments. Parenting children with ADHD may be difficult and can present challenges that create stress within the family.

    Classes in behavior management skills for parents can help reduce stress for all family members.

    Training in behavior management skills for parents usually occurs in a group setting which encourages parent-to-parent support. Behavior management skills may include the following:

    • Point systems
    • Contingent attention (responding to the child with positive attention when desired behaviors occur; withholding attention when undesired behaviors occur)

    Teachers may also be taught behavior management skills to use in the classroom setting. Training for teachers usually includes use of daily behavior reports that communicate in-school behaviors to parents.

    Behavior management techniques tend to improve targeted behaviors (such as completing school work or keeping the child's hands to himself or herself), but are not usually helpful in reducing overall inattention, hyperactivity, or impulsivity.

  • Prevention of attention-deficit/hyperactivity disorder

    Preventive measures to reduce the incidence of ADHD in children are not known at this time. However, early detection and intervention can reduce the severity of symptoms, decrease the interference of behavioral symptoms on school functioning, enhance the child's normal growth and development, and improve the quality of life experienced by children or adolescents with ADHD.

    Source: https://www.hopkinsmedicine.org/health/conditions-and-diseases/adhdadd

    Attention-Deficit / Hyperactivity Disorder | Johns Hopkins Psychiatry Guide

    Attention-Deficit / Hyperactivity Disorder (ADHD) in Children | Johns Hopkins Medicine

    • Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental, chronic disorder involving a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning or development.
    • ADHD is classified under the Neurodevelopmental Disorders section of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)[1].

      • The DSM-5 has an extensive, but not exhaustive, list of criteria for ADHD. For these detailed criteria, please see the DSM-5 itself[1].
      • The criteria-based diagnosis requires meeting of inattention and/or hyperactivity-impulsivity criteria, onset before age 12, occurrence in two or more settings, and resulting impairment in functioning.
    • Population studies suggest that ADHD occurs in most cultures in 5% of children and 4.4% of adults.
    • More frequent in males than females, with ratio of 2:1 in children and 1.6:1 in adults
      • Females may be more ly to present primarily with inattentive features.
    • Risk factors:
      • Temperament (e.g., reduced behavioral inhibition and effortful control, increased negative emotionality and novelty-seeking)
      • Environmental (e.g.

        , very low birth weight: < 1500g, in utero exposures)

      • Genetic: substantial heritability
    • ADHD is a multifaceted disorder which varies greatly in symptom type and severity.
    • Along with inattention, hyperactivity, and impulsivity, difficulties with emotion regulation, cognitive deficits, and multiple comorbidities are common (e.g., learning disorders, oppositional defiant disorder).

    • ADHD is often a lifelong disorder, with 85% of adolescents and 50% of adults exhibiting residual symptoms.
    • Poor social/interpersonal functioning and negative self-attitude are common, along with poor frustration tolerance and irritability.
    • ADHD is associated with increased risk for later depression and suicide attempts.
    • ADHD is a clinical diagnosis developmental history, clinical interview regarding symptoms/impairment, and objective ratings of inattention and/or hyperactivity/impulsivity across multiple settings, with multiple informants (e.g., parents, teachers).
    • When assessing adults, collateral and developmental data is needed to document developmental onset.
    • There is no diagnostic laboratory test or imaging modality to diagnose ADHD.
      • However, etiology-specific tests, such as TSH or serum lead levels may be helpful when hyperthyroidism or lead poisoning are suspected by history or examination.
    • In the pediatric population, common ADHD screening measures include:
      • Broad-band measures of psychopathology
        • e.g.

          , the Child Behavior Checklist, the Behavior Assessment Scale for Children

      • Narrow-band measures that are specific to ADHD and common comorbidities
    • For the adult population, there are a few ADHD-specific screening tools available for self and informant ratings:
      • e.g.

        , the Barkley Adult ADHD Rating Scale–IV, the Adult ADHD Self-Report Scale, the Conners Adult ADHD Rating Scale (CAARS)

      • Some measures focus on assessment of childhood ADHD symptoms in patients who present as adults.
        • e.g.

          , the Wender Utah Rating Scale

    • Some patients may benefit from psychological testing to clarify whether cognitive deficits should be addressed in treatment.
      • e.g., to assess for low intelligence, executive dysfunction, and learning disabilities
    • Computerized tests show modest correlations with parent and teacher ratings and do not detect inattention unique to ADHD.
    • A combination of stimulant medication and behavior therapy is first-line treatment.
    • Treatment may involve home-, clinic-, and school-based efforts.

    • Psychoeducation is useful to increase parent, teacher, and self-knowledge about ADHD symptoms and effects on behavior and emotions.
    • Family involvement and control of behaviors (e.g.

      noncompliance, oppositionality, rule-breaking) are beneficial.

    • Most youths and adults with ADHD respond favorably to psychostimulants (e.g., derivatives of methyphenidate and amphetamine).
      • Efficacy in preschoolers is more modest.
      • Common adverse effects include appetite decrease, weight loss, insomnia, and headache.

        • These may improve with dose adjustment or switching to another stimulant.
      • Coexisting substance use disorders may increase the risk for diversion of stimulants.
        • Osmotic delivery systems (e.g., Concerta) may reduce inappropriate use.
      • For young patients and any patients with difficulties swallowing pills, liquid preparations are available.
        • e.g.

          , dextroamphetamine, ProCentra, methylphenidate HCl, Quillivant

    • Nonstimulant medications have more modest effects and typically take longer to produce therapeutic responses.
      • e.g.

        , atomoxetine, guanfacine, and bupropion

      • These may be useful when stimulants side effects are intolerable, or as adjunctive treatment.
    • To optimize medication treatment, pre- and post-treatment parent and teacher ratings are recommended until adequate dosing is achieved with minimal adverse effects.
    • Behavior therapy (i.e., parent management training) is effective as front-line treatment for mild ADHD and recommended as an adjunctive treatment for moderate-to-severe ADHD.
    • Comorbid disruptive behavior (e.g., ODD) is also an indication for behavior therapy.

    • Cognitive behavioral therapy (CBT) may be appropriate in older children, adolescents, and adults with comorbid internalizing symptoms (e.g., anxiety, depression).
    • CBT in older adolescents and adults on stable stimulant doses may help manage residual symptoms of ADHD (e.g., disorganization, time management).
    • Consulting with schools about behavior management and supports is recommended.
    • ADHD is a chronic disease with early onset and frequent progression into adulthood.
    • Engagement in prosocial, healthy activities is recommended (e.g., sports, social activities, exercise).
    • Vitamins, dietary supplements, and other alternative/complementary approaches lack scientific evidence of effectiveness.
    • Pediatricians and other primary care physicians manage the majority of patients with ADHD.
      • Pediatricians are well-positioned to diagnose and treat uncomplicated ADHD.
    • ADHD without hyperactivity/impulsivity may be more difficult to detect.
    • ADHD over diagnosis and over treatment may be common in some community settings.
    • Seek psychiatrist consultation if the patient exhibits unusual reactions to stimulants or fails three trials of stimulant medications.
      • Patients with preexisting cardiac disease should undergo cardiologic evaluation prior to initiating a stimulant medication.
    • Consider referring to a child psychologist or psychiatrist when multiple comorbid conditions.
      • e.g.

        , learning issues, social problems, internalizing/externalizing disorders

    • The need for ongoing behavior therapy can be determined by a child’s level of functional impairment and co-occurring behavioral difficulties.
    • Annual medication-free periods are recommended to reassess the need for medication and optimize dosing.
    • ADHD is associated with other psychiatric disorders, notably disruptive behavior problems, internalizing disorders, and later substance use problems.
      • These will need to be addressed during treatment.

    • All ADHD subtypes in childhood predict adolescent depression/dysthymia and suicide attempts, underlining the need for ongoing treatment across development.
    • Attention and impulsivity/hyperactivity are dimensional in nature.
    1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
    2. Adler LA, Dirks B, Deas P, et al.

      Self-Reported quality of life in adults with attention-deficit/hyperactivity disorder and executive function impairment treated with lisdexamfetamine dimesylate: a randomized, double-blind, multicenter, placebo-controlled, parallel-group study. BMC Psychiatry. 2013;13(1):253.

       [PMID:24106804]

    3. Amador-Campos JA, Gómez-Benito J, Ramos-Quiroga JA. The Conners' Adult ADHD Rating Scales–Short Self-Report and Observer Forms: Psychometric Properties of the Catalan Version. J Atten Disord. 2012.  [PMID:22771453]
    4. Becker SP, Langberg JM, Luebbe AM, et al.

      Sluggish Cognitive Tempo is Associated With Academic Functioning and Internalizing Symptoms in College Students With and Without Attention-Deficit/Hyperactivity Disorder. J Clin Psychol. 2013.  [PMID:24114716]

    5. Chronis-Tuscano A, Molina BS, Pelham WE, et al.

      Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2010;67(10):1044-51.  [PMID:20921120]

    6. Greenhill LL, Pliszka S, Dulcan MK, et al.

      Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. J Am Acad Child Adolesc Psychiatry. 2002;41(2 Suppl):26S-49S.  [PMID:11833633]

    7. Kessler RC, Adler L, Barkley R, 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.  [PMID:16585449]

    8. Lara C, Fayyad J, de Graaf R, et al.

      Childhood predictors of adult attention-deficit/hyperactivity disorder: results from the World Health Organization World Mental Health Survey Initiative. Biol Psychiatry. 2009;65(1):46-54.  [PMID:19006789]

    9. McGee RA, Clark SE, Symons DK.

      Does the Conners' Continuous Performance Test aid in ADHD diagnosis? J Abnorm Child Psychol. 2000;28(5):415-24.  [PMID:11100916]

    10. Riccio CA, Reynolds CR. Continuous performance tests are sensitive to ADHD in adults but lack specificity. A review and critique for differential diagnosis. Ann N Y Acad Sci. 2001;931:113-39.  [PMID:11462737]
    11. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry. 1993;150(6):885-90.  [PMID:8494063]
    12. Wilens TE, Spencer TJ, Biederman J. A review of the pharmacotherapy of adults with attention-deficit/hyperactivity disorder. J Atten Disord. 2002;5(4):189-202.  [PMID:11967475]

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