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FEATURE Assessment and Treatment of Attention Deficit
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chiatrists it is critical that primary care Furthermore even for youth who do through chronic maltreatment or institu. providers PCPs feel comfortable and not meet ADHD diagnostic criteria high tional rearing rather than acute exposure. competent in screening assessing and levels of hyperactivity and distractibil to adverse psychosocial circumstances. managing ADHD ity are associated with poor academic that increases the risk of ADHD 2. There are however a number of fac performance which suggests that the. tors that can interfere with the proper cut off for diagnosis may be difficult to DISEASE COURSE AND PROGNOSIS. identification of appropriate cases First define and may vary from setting to set ADHD is typically identified in early. prevalence studies indicate that from the ting 13 14 Thus although clinicians must childhood Oftentimes concerns are. mid 1990s to the mid 2000s there was a exercise caution in attributing behavior first raised by teachers or other childcare. 33 increase in prevalence of this dis problems or poor school performance specialists due to high levels of disrup. order 3 This trend which coincided with to ADHD they should be mindful that tive behavior inattention or academic. increased marketing of ADHD medica up to two thirds of youth with ADHD underachievement in classroom settings. tions suggests that at least for certain go undiagnosed 15 and of those that are Due to numerous factors that limit par. children ADHD is overdiagnosed 6 Par diagnosed a majority do not receive ad ent access to specialty mental health. ticular care must be given to not mistake equate treatment 6 providers PCPs play the most critical. developmentally normative challenges role in the early identification and treat. with self regulation as symptoms of ETIOLOGY ment of ADHD It is estimated that. ADHD In a 2012 Canadian study chil Genetic vulnerability and environ youth with ADHD represent 50 of all. dren who compared to their same grade mental interactions that affect neuro children in need of psychiatric care with. peers were the youngest in their class development are both thought to play over 50 of this care being provided by. rooms were 39 more likely to receive a role in the development of ADHD PCPs 18 Although typically identified in. an ADHD diagnosis than their oldest Twin studies estimate the heritability of childhood ADHD is a chronic disease. classmates 7 ADHD to be 76 16 with multiple genes with several studies estimating 67 to. At the same time there are several each contributing a small effect impli 90 of affected individuals continuing. factors that can lead to under identifi cated 6 Examination of these candidate to have at least some impairment into. cation and treatment of this condition genes provides preliminary evidence of adulthood 19 20 As children grow their. First although boys are 2 to 3 times dysregulation of neurotransmitter sys ADHD symptoms and level of function. more likely to have ADHD than girls tems involved in dopamine norepineph al impairment may change For example. they are also more likely to be referred rine and serotonin pathways 16 whereas as children transition into adolescence. for treatment as they are compared to neuroimaging studies indicate that youth they may show a decrease in hyperactiv. girls more likely to have trouble con with ADHD have delays in cortical mat ity and impulsivity but continue to suffer. trolling their behaviors due to poor con uration 17 from inattention which may hinder their. trol of impulsivity and or hyperactivity 8 There are also a number of environ ability to successfully meet new devel. By contrast girls with ADHD are more mental factors that can impact the devel opmental challenges Moreover the cu. likely to present as inattentive versus opment of ADHD Perinatal and early mulative effects of poor academic and. overtly overactive or impulsive which developmental stress caused by expo social functioning can lead in time to. can lead to under recognition of their sure to neurotoxins eg lead maternal the development of problems with low. disorder 9 smoking while pregnant poor nutrition self esteem depression school dropout. Also unique sociodemographic during pregnancy perinatal complica substance abuse and vocational under. cultural ethnic and racial factors may tions eg toxemia or fetal traumatic achievement There is evidence that ear. contribute to under identification of brain injury and severe early depriva ly identification and treatment of ADHD. some youth with ADHD 10 For example tion all have been found to increase the can protect against some of these risks. children living in disadvantaged or ru risk of ADHD 2 Adverse psychosocial For example in a 2014 meta analysis. ral communities may have limited ac conditions such as low social economic Schoenfelder et al 21 found that consis. cess to care 11 12 In other cases parental status and poor access to maternal health tent treatment with stimulants was as. or cultural backgrounds may influence care contribute to the likelihood that sociated with lower cigarette smoking. parents willingness to have their child young children will be exposed to these rates in youth with ADHD. referred for an assessment due to con deleterious influences 2 It is important to Unfortunately consistent and com. cerns regarding the disorder s validity or note however that it is chronic psycho prehensive treatment for ADHD is dif. stigma associated with being diagnosed social deprivation such as experienced ficult to sustain The National Institute. PEDIATRIC ANNALS Vol 44 No 3 2015 115, of Mental Health Multimodal Treat ant disorder 45 50 anxiety dis for substance abuse issues in older ado. ment Study of Children with Attention orders 20 30 learning disorders lescents presenting with complaints of. Deficit Hyperactivity MTA 22 has been 20 60 mood disorders tic disor distractibility and declining school per. instrumental in both documenting the ders autism substance abuse problems formance If substance abuse is found. benefits of intensive treatment and the and conduct disorder 24 At times upon initial efforts should be directed toward. difficulties in maintaining initial gains further evaluation a clinician may de treating the substance problem If after. Although the original study results termine that either ADHD or the comor successful substance abuse treatment. clearly demonstrated that both system bid condition is primary In these cases the ADHD symptoms remain then an. atic medication management alone and care should be exercised to determine ADHD medication trial can cautiously. combined behavioral treatment and whether the secondary condition fully be undertaken 26. medication management were superior meets criteria to justify an additional di. to the two comparison groups usual agnosis For example if a teenager who DIAGNOSTIC CRITERIA. community care or behavioral manage previously never struggled with inatten ADHD consists of three primary. ment alone in reduction of impairment tion develops significant problems with symptoms inattention hyperactivity. their 8 year follow up23 found that the distractibility and poor academic perfor and impulsivity These symptoms can. original four groups no longer showed mance during the course of a depressive vary in severity from individual to in. significant differences in outcomes and episode then it is likely that the mood dividual and individually over time. that all groups were doing more poorly disorder is the cause of the distractibili but to meet a diagnostic threshold they. than the normative non ADHD com ty not ADHD Similarly it is fairly com must present to a degree that is incon. parison group The follow up study also mon for children with ADHD to develop sistent with the youth s developmental. found that children of sociodemographic symptoms of poor self esteem and peri level and cause significant impairment. and behavioral disadvantage and those odic negative mood If there is not clear Table 1 and Table 2 list current DSM 5. who had the poorest initial response to evidence of pervasive depression then criteria25 and additional diagnostic fea. treatment fared the worst regardless it likely that the mood symptoms are a tures required for a diagnosis of ADHD. of initial treatment randomization Al direct result of untreated ADHD which Notable differences between the current. though discouraging these results high hopefully will resolve with adequate and previous DSM edition27 include 1. light the importance that PCPs can play treatment of ADHD 2 the cutoff age for diagnosis being raised. in the ongoing assessment and manage If however during the assessment from age 7 to 12 years reflecting the fact. ment of children with ADHD through process the clinician finds that the pa that in some children ADHD symptoms. out development including during the tient meets full Diagnostic and Statis only become apparent with increasing. adolescent years when many youth may tical Manual of Mental Disorders fifth academic demands 2 a co occurring. fall out of treatment despite continuing edition DSM 5 25 criteria for ADHD diagnosis of autism no longer excluding. impairment and a second disorder then it will be a diagnosis of ADHD and 3 only five. necessary to make a second diagnosis instead of six criteria being required for. COMORBIDITY and develop an appropriate treatment adolescents and adults older than age 17. It is estimated that two thirds of plan for both disorders Having a sense years. youth with ADHD have an additional for the typical timing of onset of child To be diagnosed with ADHD in addi. comorbid disorder whereas 1 in 5 have hood disorders can aid the clinician in tion to meeting the requirements outlined. three or more comorbid conditions 24 determining the likelihood of distinct in Table 2 a child must present as hav. The existence of additional comorbid disorders For example both anxiety ing clinically significant symptoms that. conditions complicates diagnosis and and ADHD often begin in childhood meet criteria for one of the five follow. treatment predicts poorer functional whereas in many cases mood disorders ing subtypes The first subtype ADHD. outcomes and may necessitate a refer present several years later than symp predominantly inattentive presentation. ral to a specialty provider Using a stan toms of ADHD 2 At times if it is unclear ADHD I describes children who. dardized broadband screener such as if the patient meets criteria for a second display at least 6 of 9 symptoms of in. the Achenbach Child Behavior Check disorder it may be appropriate to begin attention The second subtype ADHD. list can help clinicians identify possible treatment for the known disorder as ef predominantly hyperactive impulsive. comorbid conditions which then can be forts continue to further assess for the presentation ADHD HI describes. evaluated further Common comorbid presence of a second disorder 10 Spe children who display at least 6 of 9. conditions include oppositional defi cial care should be given for assessing symptoms of hyperactivity impulsivity. 116 Copyright SLACK Incorporated,TABLE 1 TABLE 2, Diagnostic Criteria for ADHD in DSM 5 Additional Required. Symptoms of inattention Diagnostic Features for, Often fails to give close attention to details or makes careless mistakes in schoolwork at work ADHD in DSM 5. or during other activities The symptoms are not solely a mani. Often has difficulty sustaining attention in tasks or play activities festation of oppositional behavior. Often does not seem to listen when spoken to directly defiance hostility or failure to under. stand tasks or instructions, Often does not follow through on instructions and fails to finish schoolwork chores or duties. in the workplace Symptoms have persisted for at least 6. months to a degree that is inconsistent, Often has difficulty organizing tasks and activities.
with developmental level and that, Often avoids dislikes or is reluctant to engage in tasks that require sustained mental effort negatively impacts directly on social. Often loses things necessary for tasks or activities and academic or occupational activities. Is often easily distracted by extraneous stimuli Several symptoms were present prior. Is often forgetful in daily activities to age 12 years. Symptoms of hyperactivity Several symptoms are present in two. Often fidgets with or taps hands or feet or squirms in seat or more settings. Often leaves seat in situations when remaining seated is expected There is clear evidence that the. symptoms interfere with or reduce the, Often runs about or climbs in situations where it is inappropriate in adolescents or adults may. quality of social academic or occupa,be limited to feeling restless. tional functioning, Often unable to play or engage in leisure activities quietly. The symptoms do not happen only, Is often on the go acting as if driven by a motor during the course of schizophrenia.
Often talks excessively or another psychotic disorder The. Symptoms of impulsivity symptoms are not better explained. Often blurts out an answer before a question has been completed by another mental disorder eg mood. disorder anxiety disorder dissociative,Often has difficulty waiting his or her turn. disorder personality disorder sub, Often interrupts or intrudes on others eg butts into conversations games or activities stance intoxication or withdraw. Abbreviations ADHD attention deficit hyperactivity disorder DSM 5 Diagnostic and Statistical Manual of Mental Disorders Abbreviations ADHD attention deficit hyperactivity. fifth edition disorder DSM 5 Diagnostic and Statistical Manual of. Mental Disorders fifth edition, The third subtype ADHD combined not meet full criteria for one of the first practice assessment of ADHD in prima. presentation ADHD C describes four subtypes Unspecified ADHD is re ry care settings. children who display at least six of served for presentations where the clini PCPs should routinely screen chil. nine symptoms of both inattention and cian chooses not to specify the reason dren between the ages of 4 and 18 years. hyperactivity impulsivity The fourth sub why full criteria for the disorder are not for the presence of inattention hyperac. type other specified ADHD describes met and is commonly used in situations tive and impulsive behaviors and poor. children who present with symptoms such as in the emergency department home and school functioning during. characteristic of ADHD that cause clini where there is insufficient information office visits Additional problems that. cally significant impairment or distress to make a more specific diagnosis could also be related to ADHD such as. but who do not meet full criteria for one mood dysregulation poor self esteem. of the above diagnoses When docu ASSESSMENT aggression and poor social functioning. menting this diagnosis the clinician Both the American Academy of Pe if present should also prompt further in. must give the reason why this designa diatrics26 and the American Academy of vestigation for the presence of ADHD. tion applies eg does not meet full crite Child and Adolescent Psychiatry2 have The general necessary components of a. ria for inattention The final subtype published guidelines to aid clinicians in comprehensive assessment of ADHD in. unspecified ADHD describes children the assessment and treatment of youth clude 1 a complete history and physi. who present with symptoms characteris with ADHD Key features from these cal examination involving the patient. tic of ADHD that cause clinically signif guidelines are incorporated in the fol and one or more parents or primary. icant impairment or distress but who do lowing recommendations regarding best caregivers 2 contact with teachers or. PEDIATRIC ANNALS Vol 44 No 3 2015 117,TABLE 3 such their results need to be interpreted. in light of the full clinical presentation, Assessment Challenges and Possible Solutions It is also recommended that clinicians.
utilize broad band rating scales dur, Challenges Possible Solutions ing the course of assessment Although. Clinical time constraints and logistical Consider designating a clinical staff as a care these scales such as the Achenbach. issues eg distributing collecting and scor manager to distribute collect and score rating Child Behavior Checklist do not offer. ing ADHD rating scales scales,the specificity of ADHD specific scales. Parent teacher discrepancies in symp Collect additional collateral information inves they can be very helpful in identifying. tom reports Parent symptoms teacher tigate child parent relational problems parent other psychiatric concerns that may be. symptoms may benefit from BMT present at the time of assessment Partic. ularly for complex ADHD presentations, Parent teacher discrepancies in symp Collect additional collateral information. tom reports Teacher symptoms parent consider family or cultural attitudes regard early identification of one or more pos. symptoms ing acceptable child behavior look for other sible comorbid conditions may indicate. causes for child s disruptive behavior in school that the patient would best be served by. eg anxiety or relational conflict consider BMT a referral to a specialty provider such as. trial alone if diagnosis remains uncertain,a child and adolescent psychiatrist 10. Inadequate PCP training in ADHD or Consider referral to mental health specialist for A final type of rating scale a func. diagnostic complexity of presentation diagnosis treatment of comorbid conditions or tional assessment scale can also be. including potential high comorbidity utilizing AAP resources such as ADHD Toolkit helpful during the assessment process. Caring for Children with ADHD A Resource These assessment systems eg Adap. Toolkit for Clinicians 2nd edition 28,tive Behavior Assessment System.
Abbreviations AAP American Academy of Pediatrics ADHD attention deficit hyperactivity disorder BMT behavioral manage second edition can provide impor. ment training PCP primary care physician,tant data regarding the youth s cur. rent level of day to day functioning in, other caregivers familiar with the child s eg social relationships self care af a variety of environment situations 6. functioning and behaviors and 3 a fected and whether there are specific Functional assessment scales versus. thorough investigation of co occurring factors that exacerbate or attenuate the strictly symptom scales allow clini. disorders or other conditions that may level of impairment they cause cians to identify specific problem ar. be the primary cause or are contributing A number of validated and widely eas in functioning that can be targeted. to the patient s presentation used rating scales are available for cli and monitored for response with treat. Including parent s or other nicians to assist in the assessment pro ment One advantage of the Vanderbilt. caregiver s in the interview is essen cess 10 Narrow band rating skills such scales is that they gather narrow band. tial as young children will generally as the Vanderbilt Assessment Scale can broad band and functional data all in. not be able to provide valid and reliable be used to gather ADHD specific infor one form. information regarding their symptoms mation regarding typical symptoms In Rating scales should be obtained. and level of impairment and older chil conjunction with the clinical interview from parents caregivers teachers and. dren although better able to describe and other collateral information these other important adults in the youth s. their symptoms and functioning may scales provide data to confirm or rule life Self report rating scales are also. be hesitant to disclose or underestimate out a diagnosis of ADHD However available for adolescents Although. their impairment The PCP should use ADHD remains a clinical diagnosis adolescents often under report their. the DSM 5 to determine whether or not so therefore they should be used along functional impairment self reporting. the patient s symptoms meet the specific with and not in lieu of a complete clini allows for disclosure of ADHD symp. criteria needed to establish a diagnosis cal assessment Additionally although toms that may not be readily apparent. of ADHD The patient if appropriate they are used to quantify symptom se to parents and or teachers as many ad. and the parent should be questioned re verity both for purposes of assessment olescents do not have obvious signs of. garding the types of symptoms present and monitoring response to treatment impulsivity and hyperactivity 26 Rating. their frequency intensity and duration ADHD rating scales nevertheless re scale discrepancies among informants. their first appearance the settings in port subjective data provided by par do not necessarily rule out ADHD but. which they arise the functional domains ents teachers and other caregivers As should cue the PCP to gather more in. 118 Copyright SLACK Incorporated,formation see Table 3 to better un TABLE 4. derstand the clinical presentation, A critical component in the assess Differential Diagnoses of ADHD. ment process is to ascertain if other General medical conditions. medical neurodevelopmental psychi Medication effects eg bronchodilators corticosteroids antiseizure medications. atric or psychosocial factors are con Thyroid disorders. Lead toxicity,tributing to are comorbid with or can.
Malnutrition,better explain the youth s functional. Narcolepsy,impairments Table 4 lists a number, Sleep disorders eg sleep apnea and sleep deprivation. of potential conditions that depending Genetic disorders eg fragile X syndrome. on the clinical presentation may be of Metabolic disorders eg phenylketonuria. importance Particular attention should Brain injury. be paid to the possibility that an intel Seizure disorders. lectual deficit an undiagnosed learning Neurologic and developmental issues. disorder or a visual hearing impairment Static encephalopathy. is affecting learning or performance If Fetal alcohol syndrome. any of these concerns are suspected the Intellectual disability. PCP can request that the youth undergo Sensory impairment vision hearing. specific psychoeducational speech and PANDAS other acute onset neuropsychiatric disorders. language hearing or visual testing to Developmental disorders eg autism. explore this possibility 10 Cognitive test Learning disorders eg reading disorder. Speech and language disorders eg expressive receptive language disorder. ing in particular can also be helpful, in identifying impairments in working Psychiatric conditions. Disruptive behavior disorders eg ODD CD,memory or processing speed which are. Anxiety disorders,in some cases present in children with.
Mood disorders eg depression bipolar disruptive mood dysregulation disorder. ADHD However in general without,Obsessive compulsive disorder. clear suspicion or clear clinical indica Posttraumatic stress disorder. tion the routine use of psychoeducation Substance abuse. al and or neuropsychological testing eg Environmentally mediated problems. continuous performance testing is not Child maltreatment and bullying. recommended or considered necessary Ineffectual parenting practices. to diagnose ADHD 2 Likewise if the pa Socioeconomic disadvantage. tient s medical history is unremarkable Ineffectual classroom management. it is not necessary to pursue specific Parental psychopathology including substance abuse. laboratory imaging or other diagnostic Sociocultural factors. testing The key point here is to gather Abbreviations ADHD attention deficit hyperactivity disorder CD conduct disorder ODD oppositional defiant disorder. PANDAS pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. a complete psychiatric medical devel, opmental family and social history and Adapted from Smucker and Hedayat 29. to only pursue specific additional test,ing or specialty referrals when there is. a clear reason to suspect that other bio, psychosocial factors may be influencing feel comfortable in screening assessing ADHD symptoms during office visits. the clinical presentation and patient and and managing this condition Typically when parents present with concerns re. family complaints manifesting in early childhood ADHD garding their child s behaviors or learn. often co occurs with other psychiatric ing difficulties If ADHD is suspected. CONCLUSION illnesses such as oppositional defiant PCPs can follow up with more a more. ADHD is an impairing childhood neu disorder anxiety and learning disorders detailed assessment to confirm or rule. robehavioral disorder commonly seen in and can cause lifelong impairment if not out the diagnosis In the most cases if. primary care Due to limited access to properly identified and treated PCPs treatment is indicated and the clinical. specialty care providers PCPs need to should routinely screen their patients for picture is not overly complex the PCP. PEDIATRIC ANNALS Vol 44 No 3 2015 119, should feel comfortable in initiating 9 Biederman J Mick E Faraone SV et al dependent decline of attention deficit hyper.
Influence of gender on attention deficit hy activity disorder a meta analysis of follow. treatment and managing the illness De peractivity disorder in children referred up studies Psychol Med 2006 36 159 165. tails regarding the comprehensive treat to a psychiatric clinic Am J Psychiatry 21 Schoenfelder EN Faraone SV Kollins SH. ment of ADHD will be addressed in the 2002 159 1 36 42 Stimulant treatment of ADHD and ciga. 10 Biel MG McGee ME Assessment of atten rette smoking a meta analysis Pediatrics. forthcoming second part of this article, tion deficit hyperactivity disorder Pediatr 2014 133 6 1070 1080. Ann 2011 40 10 493 498 22 A 14 month randomized clinical trial of. REFERENCES 11 Miller TW Nigg JT Miller RL Attention treatment strategies for attention deficit. 1 Centers for Disease Control and Prevention deficit hyperactivity disorder in African hyperactivity disorder The MTA Coopera. CDC Mental health in the United States American children what can be concluded tive Group Multimodal Treatment Study of. prevalence of diagnosis and medication treat from the past ten years Clin Psychol Rev Children with ADHD Arch Gen Psychiatry. ment for attention deficit hyperactivity dis 2009 29 1 77 86 1999 56 12 1073 1086. order United States 2003 MMWR Morb 12 Sturm R Ringel JS Andreyeva T Geograph 23 Molina BS Hinshaw SP Swanson JM et. Mortal Wkly Rep 2005 54 34 842 847 ic disparities in children s mental health al MTA Cooperative Group The MTA at. 2 Pliszka S AACAP Work Group on Quality care Pediatrics 2003 112 4 308 315 8 years prospective follow up of children. Issues Practice parameter for the assessment 13 Fergusson DM Lynskey MT Horwood treated for combined type ADHD in a multi. and treatment of children and adolescents LJ Attentional difficulties in middle child site study J Am Acad Child Adolesc Psychia. with attention deficit hyperactivity disor hood and psychosocial outcomes in young try 2009 48 5 484 500. der J Am Acad Child Adolesc Psychiatry adulthood J Child Psychol Psychiatry 24 Larson K Russ SA Kahn RS et al Patterns. 2007 46 7 894 921 1997 38 6 633 644 of comorbidity functioning and service use. 3 Boyle CA Boulet S Schieve LA et al 14 Merrell C Tymms PB Inattention hyper for US children with ADHD 2007 Pediat. Trends in the prevalence of developmental activity and impulsiveness their impact on rics 2011 127 462 470. disabilities in US children 1997 2008 Pedi academic achievement and progress Br J 25 American Psychiatric Association Diagnos. atrics 2011 127 1034 1042 Educ Psychol 2001 71 Pt1 43 56 tic and Statistical Manual of Mental Dis. 4 Kessler RC Adler L Barkley R et al The 15 Jensen PS Kettle L Roper MT et al Are orders 5th ed Washington DC American. prevalence and correlates of adult ADHD in stimulants overprescribed Treatment of Psychiatric Association 2013. the United States results from the National ADHD in four U S communities J Am Acad 26 Subcommittee on Attention Deficit Hy. Comorbidity Survey Replication Am J Psy Child Adolesc Psychiatry 1999 38 7 797 peractivity Disorder Steering Committee. chiatry 2006 163 4 716 723 804 on Quality Improvement and Manage. 5 Stevens JR Wilens TE Stern TA Using 16 Faraone SV Mick E Molecular genetics of ment Wolraich M Brown L Brown RT et. stimulants for attention deficit hyperactiv attention deficit hyperactivity disorder Psy al ADHD clinical practice guideline for. ity disorder clinical approaches and chal chiatr Clin North Am 2010 33 1 159 180 the diagnosis evaluation and treatment. lenges Prim Care Companion CNS Disord 17 Shaw P Eckstrand K Sharp W et al Atten of attention deficit hyperactivity disorder. 2013 15 2 tion deficit hyperactivity disorder is charac in children and adolescents Pediatrics. 6 Feldman HM Reiff MI Clinical practice terized by a delay in cortical maturation Proc 2011 128 5 1007 1022. Attention deficit hyperactivity disorder in Natl Acad Sci U S A 2007 104 49 19649 27 American Psychiatric Association Diagnos. children and adolescents N Engl J Med 19654 tic and Statistical Manual of Mental Dis. 2014 370 9 838 846 18 Leslie LK The role of primary care physi orders 4th ed Washington DC American. 7 Morrow RL Garland EJ Wright JM Ma cians in attention deficit hyperactivity disor Psychiatric Association 2000. clure M Taylor S Dormuth CR Influence der Pediatr Ann 2002 31 8 475 484 28 Wolraich ML American Academy of Pedi. of relative age on diagnosis and treatment 19 Barkley RA ADHD long term course atrics ADHD Toolkit Caring for Children. of attention deficit hyperactivity disorder in adult outcome and comorbid disorders In with ADHD A Resource Toolkit for Cli. children CMAJ 2012 184 7 755 762 Jensen PS Cooper JR eds Attention Defi nicians 2nd ed Elk Grove IL American. 8 Groenewald C Emond A Sayal K Recogni cit Hyperactivity Disorder State of the Sci Academy of Pediatrics 2011. tion and referral of girls with attention deficit ence Best Practices Kingston NJ Civic 29 Smucker WD Hedayat M Evaluation and. hyperactivity disorder case vignette study Research Institute 2002 4 1 4 10 treatment of ADHD Am Fam Physician. Child Care Health Dev 2009 35 6 767 772 20 Faraone SV Biederman J Mick E The age 2001 64 5 817 829. Classified Marketplace, Established pediatric practice in Los Angeles seeks a part time general pediatrician with the option of taking over the. practice in the future The candidate must speak Chinese mandarin Please email CV to bn yuan yahoo com or call. manager 626 272 4659,120 Copyright SLACK Incorporated.

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