Curs Psihiatrie pediatric ADHDDr. Roxana ipoU.M.F. Iuliu Haieganu Cluj NapocaEmail: Roxana.Sipos@umfcluj.ro

Obiective1. familiarizarea cu istoricul i definiia ADHD (Tulburarea hiperkinetic cu deficit atenional)2. nvarea criteriilor de diagnostic standardizate internaional (ICD-10 i DSM V)3. nvarea algoritmului de evaluare, diagnostic i depistare a principalelor comorbiditi 4. nvarea principiilor terapeutice actuale

Coninutul cursului

Istoric i terminologieCriterii de diagnostic ICD 10, DSM IV-TR i VEvaluare i DiagnosticComorbiditiTratament

ADHD: De la tulburare comportamental la tulburare neurobiologic1902 Defect morbid al controlului moral1960 Disfuncia cerebral minim1980Deficit atenional hiperactivitate (DSM-III)1994 ADHD include subtipurile primar inatent, primar hiperactiv sau combinat (DSM-IV)1904 Sindrom comportamental post-traumatic cu hiperactivitate 1922 Tulburri de comportament post-encefalitice la copii 1968 Reacie hiper-kinetic a copilriei (DSM-II)1987 Tulburare Deficit Atenional Hiperactivitate (DSM-III-R)2000Tulburare Deficit-Atenional/ Hiperactivitate (DSM-IV-TR)190019201940196019802000

ADHD - DefiniieTulburare neurobiologic cronica care: - ncepe n copilrie - se caracterizeaz prin nivel de - inatenie - hiperactivitate nepotrivite cu dezvoltarea - impulsivitate - i care pot s se manifeste n diferite combinaii la - coal - acas - n contexte sociale

Date de prevalencea mai frecvent problem comportamental i de nvare la copiiafecteaz 3%-7% din copiii de vrst colarraportul biei - fete de 4:1fetele ar putea fi sub-diagnosticate deoarece predomin subtipul inatentprevalena este similar n diferite culturi60% dintre copiii cu ADHD manifest simptome i la vrsta adult

1. DSM-IV-TR 4th ed. 2000:85-93.

EtiologieFactorii genetici - risc de pana la 5 x mai mare la rudele de gr I i II- gene implicate n reglarea dopaminei transportorul dopaminei (DAT1)

Teoria leziunilor anatomice - dereglri ale circuitelor frontostriatale (implicate n funciile executive: atenie, memorie spaial de lucru, memoria de scurt durat, inhibiia rspunsului)disfuncie a circuitelor posterioare ale atenieiTeoria biochimic- dereglare a monoaminelor cerebrale (DA i NA)

Diagnostic: DSM-IV TRInatenie:

Minimum 6 simptome n ultimele 6 luni.

Simptomele sunt prezente la un nivel anormal pentru vrsta de dezvoltare- adesea face greeli din neatenie la coal sau n alt parte; nu d atenie detaliilor;- are dificulti n a-i menine atenia n cursul jocului sau n timpul orelor de coal;- adesea pare a nu fi atent la ce i se spune sau la ce i se cere s fac;- nu acord atenie instruciunilor i nu reuete s-i termine leciile- nu reuete s dea atenia cuvenit sarcinilor i activitilor;- i displace, evit sau devine agresiv cnd este obligat s depun un efort de atenie i mental susinut;- adesea pierde din neatenie lucruri sau obiecte care-i sunt necesare (cri, caiete, creioane, jucrii).- este foarte uor de distras de ctre orice stimul exterior;- este "uituc" n ceea ce privete orarul i activitile zilnice

Diagnostic: DSM-IV TRHiperactivitate/ Impulsivitate:- se "foiete ntr-una pe scaun" ;- de multe ori se ridic din banc n clas sau de pe scaun cand este nevoit s stea aezat mai mult timp;- cnd ar trebui "s stea cuminte" nu reuete i ncepe s alerge i s cotrobie sau s se caere;- i este foarte greu s "se joace n linite";- este tot timpul n micare, parc ar fi condus de "un motor" ;- vorbete mult, nentrebat;- rspunde nentrebat sau nainte ca ntrebarea s fi fost formulat complet;- are mari dificulti n a-i atepta rndul la jocul cu reguli;- de multe ori i ntrerupe sau i deranjeaz pe ceilali

Minimum 6 simptome n ultimele 6 luni.

Simptomele sunt prezente la un nivel anormal pentru vrsta de dezvoltare

Diagnostic: DSM-IV-TRCel puin 6 din cele 9 simptome listate pentru oricare domeniu sau pentru ambele, timp de cel puin 6 lunisimptomele au debutat naintea vrstei de 7 aniafectare semnificativ clinic n dou sau mai multe contexte (la coal, acas, social)Simptomele nu apar exclusiv n cadrul unei alte tulburri mintale.

Criterii de diagnostic DSM-IV vs. ICD-10

Subtipurile clinice DSM IV TR

Predominant inatent

Tip combinat

Predominant hiperactiv-impulsiv

ICD 10- F90 Tulburari hiperkineticeF90Tulburri hiperkineticeF90.0Perturbare a activitii i atenieiF90.1Tulburare hiperkinetic de conduitF90.8Alte tulburri hiperkineticeF90.9Tulburri hiperkinetice nespecificate

Schimbari DSM-VSimptomele trebuie s fie prezente naintea vrstei de 12 aniPentru adolesceni (>17) i aduli sunt suficiente 5 criterii dintr-un domeniu sau ambele, pentru diagnosticTulburrile pervazive de dezvoltare nu mai constituie un criteriu de excludereADHD este inclus ntr-o nou categorie Tulburri Neurodevelopmentale

HiperactivitateImpulsivitateInatenieADHD:Evoluie

ADHDStim de sine sczutRezultate academice slabeRelaionareFumat, abuz de substaneSe lovesc frecventAccidente rutiereProbleme legaleOcupaie/vocaieCopiiAduliAdolesceniDomenii afectate

Tablou clinicPrecolar

Nelinite motorie (ntotdeauna pe picior de plecare)Agresivitate (i lovete colegii)mprtie lucrurileCuriozitate de nestpnitFr fric se poate lovi pe sine sau pe ceilaliNivel sczut de complianntrerupe pe ceilaliCere foarte mult atenie, argumenteaz, pn la a deveni plictisitor

Tablou cliniccolarDistras cu uurinFace greeli din neglijen la temele colareRezultate slabe la scoalFrecvent chemat la discuii cu diriginteleRspunde nainte ca ntrebrile sa fie ncheiatentrerupe sau deranjeaz orancredere sczut n sinePierd lucruriAgresivitateDificulti de a iniia / menine relaii cu ceilali copiiNu i ateapt rndulPercepia de imaturitatePredispus la accidente

Tablou clinicAdolescenPot avea un sentiment de tensiune interioar, mai degrab dect hiperactivitatencpnai, dezorganizare n activitatea colar, follow up insuficientNu pot lucra independentRelaionare dificilaInabilitate de amna Dificulti specifice de nvareComportamentul este dificil de modificat de recompensa sau pedeapsaAngajat n activiti cu risc (vitez, abuz de droguri,sex neprotejat)Incapacitatea de a respecta autoritatea

Evaluare i DiagnosticThe National Institute for Health and Clinical Excellence (NICE)September 2008 last modified: March 2013/ AACAP 2007Echip multidisciplinarMedic specialist psihiatrie pediatricPsiholog clinicianLogoped Medic specialist pediatruMedic de familieMedic specialist neurologie pediatricAsistent socialConsilier colar

informaiile existente din toate contexteleanamneza specific/evalurile efectuate de specialiti cu experien i pregtire corespunzatoareobservaii concentrate n mai mult de un mediu

Evaluare i DiagnosticThe National Institute for Health and Clinical Excellence (NICE)September 2008 last modified: March 2013/ AACAP 2007Interviu clinic cu prinii i copilulScreening pentru simptomele ADHDIstoric medical cu accent pe datele privind naterea i traumeIstoric familial de ADHD, alte tulburri psihice, probleme neurologice sau dificulti psihosocialeMedicaie, istoric social, istoric developmentalPrinii pot completa diferite scaleEvaluare colarRapoarte asupra comportamentului, abilitilor de nvare, prezen, medii i note la testriEvaluare pshoeducaional abiliti intelectuale, dificulti de nvareProfesorii pot completa scale

Instrumente de evaluareCele mai utilizate i validate instrumente sunt:

Child Behavior Checklist pentru priniTeach Report Form of the Child Behavior ChecklistScalele Connor pentru prini i nvtoriSNAP IVADHD-RS

Evaluare i DiagnosticThe National Institute for Health and Clinical Excellence (NICE) September 2008 last modified: March 2013/ AACAP 2007

Evaluarea - realizarea profilului ! Nu folosire izolata n scop diagnostic a scalelor

Abiliti intelectuale, stil de nvareLimbaj i comunicareAbiliti motorii grosiere/fineComportamente adaptativeStarea emoionalAbiliti socialeStare de sntate general, nutriia

Profil puncte forte/deficite/nevoi managementul cazului

Comunicarea rezultatelor fiecarei evaluri familiei

Examenul fizicInclude:

Examinarea parametrilor fizici i situarea pe curbele de cretere (G, T, BMI)Semne vitale, inclusiv TA, EKG (la nevoie)Screening pentru probleme senzoriale (vz, auz)Examen neurologic (la nevoie)

Diagnosticul diferenialTulburari psihiatriceUzul/abuzul de substaneTulburri afectiveTulburri de adaptareTulburri psihoticeTulburri anxioaseDeficite de nvare i limbajStres Afeciuni medicaleApneea de somnTulburri developmentaleFolosirea unor medicamenteEpilepsieAfeciuni tiroidieneTulburri de acuitate vizual, auditiv

ComorbiditiNumai ADHD Tulburarea de opoziie39.9%Tulburri anxioase38.7%Tulburri de conduit14.3%N=579Ticuri10.9%ADHD31.8% tulburarea de opoziie; tulburri de conduit; tulburri de nvare; depresie i/sau anxietate; dificulti de dezvoltare a vorbirii i limbajului; afectarea dezvoltrii coordonrii. Cele mai frecvente co-morbiditi asociate cu ADHD sunt :

3,8%Tulburriafective

Tratament

Obiective:formarea relaiei terapeutice cu pacientul i familiaconsimmnt verbal/scris al pacientului/aparintorului pentru evaluare/intervenieterapia dureaz mai muli ani, uneori i la vrsta adultEficacitate asupra simptomelor principale InatenieImpulsivitatehiperactivitate Beneficii suplimentare (integrare familial i social, performan colar, etc.)Pentru medicaie: siguran n administrare faza acut i pe termen lung

Optiuni terapeuticeAdaptarea tratamentului la profilul pacientului i resursele existente

Educarea prinilor/pacientului despre ADHDTerapie comportamentalTerapie medicamentoasSuport educaional

Tratament medicamentos

Medicaie stimulat: Methylphenidate (Ritalin, Concerta, Medikinet), Dextroamphetamine (Dexedrine), Dextro si Levoamphetamine (Adderall), Pemolin (Cylert)Medicaie nonstimulant: Atomoxetina (Strattera)

Antidepresive triciclice: Imipramina,DesipraminaAntidepresive: ISRS, BupropionAntipsihotice: Haloperidol, RisperidonaAnticonvulsivante: Carbamazepina, Acid valproic i valproat de sodiuAntihipertensive: Clonidina

Tratament medicamentos- dozare

MedicaieDoza de startDoza maximAdministrareRitalin5 mg 1-2x/zi0.8 2.0 mg/kg/zi1-3x/ziConcerta18 or 36 mg /zi18-54 mg/zi1/ziStrattera0.5 mg/kg/zi1.5-1.8 mg/kg/zi1/ziMedikinet10 20 mg/zi20 40 mg/zi1-2/zi

Tratament medicamentos- efecte adverseStimulante

Scderea apetituluiInsomnieAnxietateIritabilitateLabilitate emoionalDureri abdominaleCefalee

Nonstimulante

Scderea apetituluiDureri abdominaleGreaa, vrsturiIritabilitateLabilitate emoional

Tratament medicamentosMedicamentele aprobate pentru copii cu vrsta peste 6 ani de ctre Agenia Naional a Medicamentului din Romnia: STRATTERA (atomoxetina), CONCERTA (metilfenidat) i MEDIKINET (metilfenidat).Dac apar efecte adverse se recomand, n funcie de severitatea acestora: monitorizare, ajustarea dozelor de medicament, schimbarea medicamentului, medicaie simptomatic.Terapia farmacologic este indicat ct timp simptomele persist i cauzeaz disfuncionalitate.

Monitorizare tratament medicamentos

greutate, nlime, BMI (baseline/lunar)puls, TA (baseline/lunar)probe laborator: hemoleucograma, TS, TSH, FT3/4, TGO/TGP, glicemia, uree, creatinina (baseline/6luni/1an)EKG (interval QT) (baseline/1an)EEG (baseline/la nevoie)

Cnd este indicat tratamentul medicamentos?

simptomatologia ADHD de intensitate medie sau sever, la copii de vrst colar sau mai mari

afectare important a funcionrii care nu rspunde la terapia comportamental sau psihoeducaie

AACAP. J Am Acad Child Adolesc Psychiatry. 1997;36:85S-121S.Intervenia psihologicnelegerea afeciunii (psihoeducaie)Cauz medicalNu se datoreaz educaiei defectuoaseIntervenie comportamentalAsigurarea unei structuri i a rutinelor predictibile la clas, utilizarea unor fie de raportare zilnicModificri comportamentale n familie, la serviciu/coal, activiti recreativeStructurarea activitilor, liste, aciuni cu feedback imediatFeedback/Monitorizare

Tehnici comportamentaleStrategii specifice

Sistemul de recompens Time out ntrire social Modelare comportamental

Suport pentru priniEducaia familiei i pacientului

Intervenii pe puncte de performanInstruirea prinilor n tehnici de modificare comportamentalStimularea comportamentului pozitiv i corectarea celui negativ Stabilirea i urmarea regulilor Fi de raportare zilnic de lucru cu aciunile int de la coalPerformana colarIndividual sau pe grupuri, ntlniri pentru rezolvarea temelor etc.Focus pe urmrirea direciilor, ncadrarea n termen i abordarea tehnicilor de nvareInterveniile psihosociale

Interveniile psihosocialenvarea abilitilor sociale, a tehnicilor de stpnire a anxietii sau furieiSe adreseaz unui comportament specific (de ex. agresivitatea la locul de joac)Stimularea abilitilor de rezolvare a conflictului, tactic axat pe soluii, CBT (terapie cognitiv-comportamental)

Evoluie

Precolar Adolescent Adult colar Adult tnrProbleme comportamentaleProbleme comportamentaleDificulti colareDificulti de relaionareStim de sine deficitarDificulti colareDificulti de relaionareStim de sine deficitarProbleme legale, fumat, vtmri/loviriEec colarDificulti profesionaleStim de sine deficitarAbuz de substaneVtmri/accidenteEec profesionalStim de sine deficitarDificulti de relaionareAbuz de substaneVtmri/accidente

Concluzii ADHD poate persista i la adult. Simptomele ADHD sunt insuficient recunoscute i tratate n serviciile de asisten medical primar. Copiii de la 4-18 ani pot fi diagnosticai i tratai pentru ADHD. Terapia farmacologic (stimulante, inhibitori selectivi ai recaptrii noradrenalinei atomoxetina, alfa adrenergicele) i terapia comportamental sunt eficiente i sigure n tatamentul ADHD. Terapiile eficiente necesit titrare adecvat i monitorizare continu pentru a ramane eficiente.

Intrebri?

BibliografieDiagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington (DC). American Psychiatric Association, 2000.

International classification of mental and behavioral disorders. Clinical descriptions and diagnostic guidelines, 10th ed. Geneva: World Health Organization,1992.

Kaplan & Sadocks Comprehensive TextBook of Psychiatry, eighth edition. Editors Benjamin J. Sadock, Virginia A. Sadock, volume two, ed. Lippincott Williams & Wilkins, 2005.

BibliografieAmerican Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children, adolescents and adults with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 36 (suppl 10):085S-121S, 1997http://publications.nice.org.uk/attention-deficit-hyperactivity-disorder-cg72/changes-after-publicationManual de psihiatrie al copilului i adolescentului. Iuliana Dobrescu, ed. InfoMedica, Bucureti, 2009.

Va mulumesc!

*** Key Points:ADHD: Behavioral Disorder to Brain Disorder Historically ADHD was thought of as a behavior disorder now research supports that it is a brain disorder. The long history of ADHD has been accompanied by many changes in the disorders label, reflecting the evolving theories of the researchers studying the disorder. From the 1930s to 1950s, emphasis was placed on the relationship of these symptoms to brain insults, including infections, toxins, and head trauma. The term minimal brain damage was coined but was later (in the 1950s and 1960s) changed to minimal brain dysfunction. Hyperactivity began to play a central role in diagnosis and etiologic hypotheses in the late 1950s, when scientists began to understand the interrelated roles of the cortex, thalamus, and basal ganglia in the regulation of motor behavior. The term hyperkinetic reaction of childhood was used, and the use of stimulants became much more widespread n the 1960s. In the 1970s, researchers once again began to consider the deficit n sustained attention as having a central role rather than being an associated phenomenon, and it was renamed attention deficit disorder.

*Key points:ADHD A DefinitionThe current diagnostic label for this neurological disorder incorporates the three principal hallmark symptoms: inattention, hyperactivity (may not be present in all children), and impulsive behavior.While shades of all of these three symptoms are present to varying degrees in all children, the key operative diagnostic qualifier is the careful evaluation of what constitutes inappropriate behavior leading to problems in social, scholastic, family and work environment. The test of inappropriateness rests on identifying symptoms that are maladaptive and inconsistent with developmental level. Consequently, it is not easy to precisely define ADHD, and it may never occur n its pure form. However, it is a distinct clinical disorder greatly in need of early detection and treatment.

Question/Transition: What kind of impact do you think this disorder has on society?

References:American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Text Revision. Washington, DC, American Psychiatric Association, 2000.* Key Points:DSM-IV-TR Diagnostic Criteria for ADHD The DSM-IV-TR diagnostic criteria emphasize several factors including the persistence of the symptoms (at least 6 months). Also, the symptoms must be maladaptive and inconsistent with the normal developmental level and lead to clinically significant impairment. Although the tenth revision of the International Classification of Diseases (ICD-10) recognizes 3 symptom domainsinattention, impulsivity, and hyperactivityin DSM-IV-TR, impulsivity and hyperactivity are considered 1 domain.

Question/Transition: Can anyone give some examples of symptoms for each category?*Key Points:ADHD Clinical Sub-typesDSM-IV-TR adopted the two-dimensional (inattention and hyperactivity/impulsivity) diagnostic criteria forming three sub-types that include predominantly inattentive, predominantly hyperactive-impulsive, and combined types. The reported proportions of sub-types of ADHD within those diagnosed with the condition were as follows: predominantly inattentive type, 49 to 56%; hyperactive-impulsive type, 16 to 22% ; combined type, 23 to 29%.Poor academic performance is the hallmark of children with the predominantly inattentive type of ADHD. This sub-type has a lower incidence of comorbidity for oppositional defiant disorder (ODD) and conduct disorder (CD).On a comparative basis, the prevalence of the inattentive type of ADHD is higher n girls.Children in the hyperactive-impulsive sub-type are more prone to behavior than academic problems. These children are also less likely to develop anxiety or depressive symptoms.Children with the combined sub-type of ADHD demonstrate a high percentage of both academic (~ 55%) and behavioral (~ 78%) problems. This group also has the highest prevalence of comorbidities and is the most impaired sub-type assessed by impairment scores.

Question/Transition: It was mentioned earlier that females are under-diagnosed because they are over represented n the inattentive subtype, why would that make it harder to diagnose?References:Baumgaertel A, et al. Attention deficit disorders in a German elementary school-aged sample. J Am Acad Child Adolesc Psychiatry 1995;34:629-38.Lahey BB,Applegate B,et al. DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents. Am J Psychiatry.1994;151:1673-85.Wolraich, ML, Hannah JN, et al. Examination of DSM-IV criteria for attention-deficit/hyperactivity disorder in a county-wide sample. J Dev Behav Pediatr 1998;19:162-8.Wolraich, ML, Hannah JN, et al. Comparison of diagnostic criteria for attention deficit hyperactivity disorder in a county-wide sample. J Am Acad Child Adolesc Psychiatry 1996;35:319-323.**Teoria 1. creier normal- injurii/traume/infecii n per de dezvoltare schimb structura cerebral Teoria 2. dezv creierului fetal este defect, nu este evident n primii ani i anumii strsori n timpul maturrii declanez tulbTeoria 3. predispoziie genetic afecteaz creierul n trim II iu crete vulnerabilitatea la complicaii natere/sarcin duc la afectare periventricularInteraciune fact genetici-mediuInteraciunea factori psihologici, sociali i factori de boal este complex i bidirecionalVal prag boala se manifestaSubprag tulb din spectru schizotipal*Teoria 1. creier normal- injurii/traume/infecii n per de dezvoltare schimb structura cerebral Teoria 2. dezv creierului fetal este defect, nu este evident n primii ani i anumii strsori n timpul maturrii declanez tulbTeoria 3. predispoziie genetic afecteaz creierul n trim II iu crete vulnerabilitatea la complicaii natere/sarcin duc la afectare periventricularInteraciune fact genetici-mediuInteraciunea factori psihologici, sociali i factori de boal este complex i bidirecionalVal prag boala se manifestaSubprag tulb din spectru schizotipal**Key Points:The differential diagnosis of ADHD versus other types of disruptive behavior disorders is generally straightforward by clinical history and examination of specific symptoms and behavior patterns. Descriptions of inattention, overactivity, and impulsivity should be evident across situations and to multiple observers. Other sources of inattention and frustration in school settings, such as learning disorders, can be discerned by differences in behavior across settings, school grades, and results of psychoeducational evaluations. At times, these problems may co-occur, making accurate diagnosis more complex.Another diagnostic challenge lies in separating interference from other psychopathology such as mood or anxiety disorders on concentration, school/work adjustment, and performance. In general ADHD is distinguished by its chronicity and early onset rather than an episodic pattern, although school/work impairment from ADHD may be progressive, with increasing academic demands over many years. The temporal relationship between the appearance of internalizing symptoms with greater school difficulty usually is evident in instances of mood or anxiety disorders uncomplicated by ADHD.A variety of other psychiatric and developmental disorders are commonly associated with ADHD, including pervasive developmental disorders, schizophrenia, and mental retardation. In most instances, these disorders, if diagnosed, are consider primary, and a separate diagnosis of ADHD is not made, although interventions to enhance concentration, reduce interfering symptoms, and improve academic performance may be an important part of treatment efforts.

ReferencesMcCracken JT. Attention-deficit disorders. n: Sadock BJ, Sadock VA, editors. Kaplan & Sadocks Comprehensive textbook of psychiatry, volume II. 7th ed. Philadelphia:Lippincott Williams & Wilkins; 2000. p. 2679-2688.

Comorbidity of ADHD with other disorders is the rule, rather than the exception. 69% of children with ADHD have one or more coexisting conditions (including major depression, conduct disorder, oppositional defiant disorder, Tourettes syndrome, and learning disabilities), these conditions may complicate a diagnosis of ADHD1. The primary care physician may more easily identify and target these other conditions, thereby missing the ADHD diagnosis. Some medications for ADHD may exacerbate some comorbid conditions. A note about the MTA study sample and potential sample bias: In the MTA study, the investigators set out to enlist a very heterogeneous sample: they actively recruited girls, sought out children with disparate comorbid diagnoses, and attempted to include children and families either currently receiving treatment or who are amenable to intervention.2 The latter decision took sample recruitment beyond clinic referrals into the general population, where advertisements, word of mouth, and other methods were used to stimulate self-referral. On one level, the enlistment strategies developed in the MTA study appear to be very inclusive: all children with ADHD, irrespective of clinic status, were eligible for study. The limiting factor behind this strategy is the lack of control over the factors determining self-selection. These factors or sample filters condition the identification and take-up of subjects and come in 2 forms: referral filters, which control the movement of the subject pool toward the site, and study filters, which control the enlistment and retention of study subjects.3Another limitation regarding this study was the sample group was restricted to the Combined type of ADHD. Inattentive type has a different comorbidity profile than combined type.

Jensen P, et al. Moderators and mediators of treatment response for children with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999;56:1073-1096. Hinshaw SP, March JS, Abikoff H, Arnold LE, Cantwell DP, Conners CK, and others. Comprehensive assessment of childhood attention-deficit hyperactivity disorder in the context of a multisite, multimodal clinical trial. Journal of Attention Disorders 1997;1:21734. Boyle MH, Jadad AR. Lessons from large trials: the MTA study as a model for evaluating the treatment of childhood psychiaric disorder. Can J Psychiatry 1999;44:9918. **Over 60% of childhood ADHD continues into adulthood1.

1. Baren M. ADHD in adolescents: Will you know it when you see it? Contemporary Pediatrics 2002; 19: 124-141.