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Attention-Deficit/Hyperactivity Disorder


John D. McLennan, MD, PhD, FRCPC Child Psychiatry Consultant University of Calgary Pediatric Resident Seminar Jan 17, 2013 – PowerPoint PPT presentation

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Title: Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder
  • John D. McLennan, MD, PhD, FRCPC
  • Child Psychiatry Consultant
  • University of Calgary
  • Pediatric Resident Seminar
  • Jan 17, 2013

  • I have no conflict of interest to declare
  • None to declare

Why a whole lecture focused on ADHD?
  • Common
  • Significant Impact
  • Risk for scholastic problems
  • academic underachievement, grade retention, drop
  • Risk for relationship/social problems
  • Risk for employment problems
  • Risk for physical health problems
  • E.g., motor vehicle accidents

  • Diagnostic aspects
  • Intervention aspects
  • Other

A. Diagnostic aspects
  1. ADHD as a categorical disorder
  2. ADHD as a dimensional phenomenon
  3. Prevalence/etiology/prognosis
  4. ADHD and comorbidity
  5. Recommended diagnostic approach
Diagnostic Criteria for ADHD(American
Psychiatric Association, 1994)
Details Example
A (1). Six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities Often has difficulty sustaining attention in tasks or play activities (a total of 9 symptoms listed)
A (2). Six (or more) of the following symptoms of hyperactivity-impulsivity . Often fidgets with hands or feet or squirms in seat Often blurts out answers before questions have been completed (a total of 9 symptoms listed)
B Some (of these) symptoms have caused impairment were present before age 7 years Some (of these) symptoms have caused impairment were present before age 7 years
C Some impairment present in at least 2 settings Some impairment present in at least 2 settings
D Clear evidence of significant impairment Clear evidence of significant impairment
E Not occurring exclusively during certain other disorders Not occurring exclusively during certain other disorders
DSM-IV ADHD subtypes
  • Combined
  • Predominately, hyperactive-impulsive
  • Likely just a precursor of combined type or just
    milder form
  • Predominately, inattentive
  • Some previously combined type
  • Some sub-threshold combined type
  • Some sluggish cognitive tempo?
  • Not-otherwise-specified (NOS)

Sluggish Cognitive Tempo
  • Forgetful, daydreams, sluggish, drowsy
  • Hypoactive
  • in a fog
  • Slow to process information/ more errors with
    information processing
  • Socially passive, withdrawn
  • McBurnett et al., 2001

Proposed changes in DSM-5 for ADHD (May 2012)
SEE for more details (..release date
May 2013?)
Change Issue
Change age of onset Change age of onset from 7 to 12 and just require symptoms (not impairment) at age of onset
Change in subtypes -Change subtype to a specifier for presentation (as more variation in degree rather than kind, lack of stability over time) -add 4th option (inattentive presentation-restrictive)
Change/expand symptom examples -to better capture lifespan relevance
Remove PDD from exclusion criteria Many children with PDD (pervasive developmental disorder) or Autism Spectrum Disorder have significant ADHD symptom clusters
Explicitly recommend multiple informants Pre-amble now includes recommendation to obtain information from 2 different informants
Categorical vs. Dimensional
  • While ADHD is often conceptualized or promoted as
    a categorical entity, it probably better fits on
    a spectrum
  • Consider degrees of attentional weakness and poor
    impulse control
  • Setting a diagnostic cut-point on a spectrum
  • Hypertension analogy (140/90, not 139/89)

Attention regulation
The Dimension of ADHD
Strengths and Weaknesses of ADHD-symptoms and
Normal-behaviour (SWAN rating scale)
Far below average Below average Slightly below average Average Slightly above average Above average Far above average
Give close attention to detail and avoid careless mistakes
Sustain attention on tasks or play activities
Listen when spoken to directly
  • Support provided by a study of the heritability
    of attention problems in a Norwegian twin study
    (Gjone et al , 1996)
  • No change in relative genetic influence across
  • Lacking evidence of a taxon (Coghill
    Sonuga-Barke, 2012)

Social construction?
The dimensional nature of ADHD and indistinct
boundaries with a normal range of behaviours may
result in the notion of it being a socially
constructed disorder..although this is true of
well-established medical disorders as well
  • DSM-IV criteria
  • Estimated about 5 prevalence (Polanczky et al.,
  • Higher in clinical samples
  • Boysgtgirls (more pronounced in clinical samples)
  • Inattentive typegtcombined type?

Etiology Points Genetics
  • Family aggregation studies
  • If parent has ADHD, risk to offspring about 57
  • Risk to sibling approximately 32
  • Twin Studies
  • Average heritability 80
  • Shared environment contribution 0-13
  • Non-shared environment 9-20
  • Also support from adoption research
  • Molecular genetic research
  • DRD4 (gene for dopamine 4 receptor) 7 repeat
  • 13p16 region of chromosome 16?

  • (Barkley, 2006)

Etiology Points Brain structure function
  • Some studies identified smaller brain regions
    total brain volume, prefrontal volume, caudate
    nucleus, cerebellum-vermis (Barkley, 2006
    Steinhausen 2009)
  • Evidence of dysfunction of the frontostriatal
    networks and possible other networks/regions
    (Cherkasova Hechtman 2009)
  • Developmental lag in cortical grey matter
    thickening/maturation in childhood (Shaw et al.,
  • Decreased cortical thinning in adolescents (Shaw
    et al., 2011)
  • Others (Barkely 2006)
  • Deficits on neuropsychological testing (e.g.,
    executive functioning)
  • Quantitative EEG increased slow wave in frontal
    lobe decreased beta activity
  • Decreased blood flow to prefrontal regions
  • Low birth weight, white matter abnormalities,
    brain injuries (though likely only small

Etiology Points Other
  • Environmental Toxins?
  • Lead, alcohol, nicotine (Linnet et al., 2003)
  • Psychosocial Factors?
  • Not etiologic, parenting behaviour may contribute
    to maintenance/worsening of oppositional
  • Other?
  • Sugar (no)
  • Additives (maybe) Artificial food colours (Schab
    Trinh, 2004)
  • Medication (Phenobarbital)
  • Streptococcal infection
  • (Barkley 2006)

  • Increasingly recognized as a chronic disorder
  • Estimate that 50-70 of childhood ADHD persists
    into adolescence cases (could be higher
    depending on criteria/measurement)
  • Significant heterogeneity
  • Substantial co-morbidity influences prognosis and

ADHD comorbidities
  • Comorbidity the presence of one or more
  • It is often ADHD AND ____ rather than ADHD OR
  • Common types of co-morbidities
  • Oppositional Defiant Disorder or symptom
    cluster of
  • Learning Disorder or symptom cluster of
  • Conduct Disorder or symptom cluster of
  • Anxiety Disorder or symptom cluster of
  • Depressive Disorders or symptom cluster of
  • Tic Disorders or symptom cluster of

The spectrum of ADHD co-morbidities
ADHD Alone
ADHD symptoms of another disorder
ADHD Other disorder
Other disorder some symptoms of ADHD
Dr. Gabrielle Carlson, Stony Brook University
Medical Centre
ADHD Comorbidity
  • Kadesjö GiIlberg, 2001 (Swedish population

Diagnosis ADHD (n15) Subthreshold ADHD (n42) No ADHD (N352)
Oppositional Defiant Disorder 60 12 1
Developmental Coordination Disorder 47 47 9
Reading/writing Disorder 40 29 7
Tic Disorders 33 12 2

At least 1 comorbid diagnosis 87 71 17
At least 2 comorbid diagnoses 67 36 3
Poor emotional regulation
  • Common in children with ADHD
  • May be (Wehneier et al, 2010)
  • Inherent in the disorder
  • Associated with comorbidity
  • Secondary/consequence of ADHD
  • Emotional impulsiveness (Barkley 2010)

What strategies would you use to obtain
information to make a diagnosis of ADHD?
Some ADHD diagnostic points
  • You must get teacher data
  • Use standardized checklists
  • Consider patterns on the checklists
  • Childs behaviour in the office
  • Remember comorbidities

Teacher data/information (Essential)
  • To make an ADHD diagnosis, you must have school
  • Relying exclusively on parent report about
    school-behaviour is inadequate
  • Parents dont have systematic data from school
  • Parent-teacher agreement is moderate to low
  • If a child is not manifesting ADHD behaviour in
    the classroom, they dont have ADHD
  • Teachers
  • typically have access to a normative sample to
    inform their ratings
  • Have a relatively standardized setting
  • At least some experience with typical development
  • Often substantial observation periods to draw

Use standardized checklists
  • A best practice recommendation
  • Provides systematic coverage of ADHD items (and
    symptoms of comorbidities)
  • Greater reliability than clinical interview, but
    not a substitute for a clinical interview
  • Parent AND TEACHER

Standardized Ratings
  • Narrow/focussed (e.g., primarily measure ADHD
  • ACTors
  • Short Connors
  • Broad-band (could help cover potential
  • Child Behavioral Checklist (CBCL)Achenbachs
  • Behavior Assessment System for Children (BASC)
  • Informant types
  • Parent/Caregiver
  • Teacher
  • Child
  • Disagreement between informants common

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Child behaviour in office
  • Dont use behaviour in the office as a proxy for
    behaviour at school or home
  • Beware of false negatives
  • Novel stimulating environment

Remember comorbidities
Questions about diagnosis, assessment, etc
B. Interventions
Evidence-based treatments
  • What are the evidence-based interventions for
  • Only 2 interventions with rigorous evidence of
    effectiveness for ADHD
  • Certain behavioural modification techniques
  • Certain medication
  • Many other interventions out there
  • some with a little evidence
  • some with no evidence

Stimulant options in Canada
  • Methylphenidate based products
  • Immediate release (Ritalin, generic)
  • Extended release
  • CR (Biphentin)
  • OROS (Concerta generic?)
  • SR (Ritalin SR)
  • Amphetamine based products
  • Immediate release dextroamphetamine (Dexedrine,
  • Sustained release dextroamphetamine (Dexedrine
  • Extended release - mixed salts of amphetamine
    (Adderall XR)
  • dextroamphetamine sulfate
  • dextroamphetamine saccharate
  • amphetamine aspartate monohydrate
  • amphetamine sulfate
  • Lisdexamfetamine (Vyvanse)
  • Lysine dextroamphetamine (pro-drug)

Methylphenidate mechanism
  • A CNS stimulant
  • Mechanism(?) increase intra-synaptic
    concentration of dopamine and noradrenaline in
    frontal cortex and subcortical brain regions
    associated with motivation and reward (Volkow et
    al., 2004, in NICE guidelines)
  • Blocks presynaptic membrane dopamine transporter
    (DAT) inhibits reuptake of dopamine and
    noradrenaline into presynaptic neurons

Dextroamphetamine mechanism
  • More potent than MPH
  • In addition to blocking reuptake of dopamine and
    noradrenaline via the dopamine transporter (DAT)
    it also releases dopamine and noradrenaline into
    the extraneuronal space by blocking intraneuronal
    vesicular monamine transporter (VMAT)

Non- Stimulants
  • Atomoxetine (Strattera, generic)
  • Selective norepinephrine reuptake inhibitor
  • Approved in Canada for ADHD
  • Others (available but not approved for ADHD)
  • Bupropion (Wellbutrin SR and XL, Zyban, generics)
  • Nortriptyline (Aventyl, generics)
  • Imipramine (Tofranil, generics)
  • Clonidine (Catapres, Dixarit, generics)
  • Guanfacine (Tenex) special order only
  • Guanfacine extended release Intuniv under
    review in Canada
  • Desipramine and Pemoline are no longer used

Medication choice
  • What would you start with?
  • What would inform your decision?
Medication Choice/Order
  • Texas Algorithm Project (Pliszka et al., 2006)
  • 1st choice stimulant
  • Methylphenidate or amphetamine
  • 2nd choice stimulant from other class
  • Methylphenidate or amphetamine
  • 3rd choice atomoxetine
  • Are there exceptions where you would chose
    atomoxetine earlier?
  • 4th choice other monotherapy

Factor informing choice
  • What period of time to cover?
  • School only vs. beyond school
  • Can the child swallow?
  • Have to be able to swallow for methylphendiate
    OROS (Concerta) and atomoxetine (Strattera)
  • Are non-generics affordable?
  • History of medication use/response (including
  • Genetic testing not yet

Medication management Stimulants
  • What do they do?
  • Increase attention span
  • Decrease hyperactivity
  • Decrease impulsivity
  • Sometimes
  • Reduce aggression
  • Improve socialization
  • Some measures of school performance (short-term)
  • Reduce emotional dysregulation
  • Improve compliance

Stimulant side-effects Physical
  • Gastrointestinal/Appetite/Growth
  • Decrease appetite (ensure balanced diet, calorie
  • Weight loss (as above monitor)
  • Upset stomach (take with food)
  • Decrease stature (mean of 1.2cm at 14 months in
    MTA study)
  • Cardiovascular
  • Increased pulse (monitor, not typically a
  • Increased blood pressure (monitor, not typically
    a problem)
  • Sudden (Cardiac) Death not evidence of
    increased risk but
  • Screen for family history of sudden cardiac death
  • Screen for factors increasing risk for unexpected
    cardiac death
  • Baseline physical/cardiovascular exam
  • ECG not required if normal exam and history
  • could miss Long QT syndrome and WPW

Stimulant side-effects Emotional and others
  • Increased proneness to tears
  • Agitation/irritability
  • Too quiet/glassy eyed/zombie appearance,
    flat/depressed (dose too high)
  • Tics (obtain family history, monitor, possibly
    discontinue, controversy)
  • Other
  • Headaches
  • Insomnia (may be an issue with late dosing or
    longer-acting formulations)
  • Generally unfounded societal worries
  • Personality change
  • Entry to drug abuse addiction

  • Selective norepinephrine reuptake inhibitor
  • Primarily metabolized in the liver via cytochrome
    P450 2D6 (CYP2D6 pathway)
  • Slower titration than the stimulants (as may be
    lag in the attainment of maximum response to a
    given dose)
  • Dose/body weight recommendations
  • Maximum of 1.4mg/kg/day (or 100mg, whichever is
  • Start dose recommendation 0.5mg/kg/day
  • Typically once per day dosing (but can spilt
    dose am and late afternoon/early evening)

Atomoxetine- adverse effects
Common Adverse Effect Number Needed to Harm (NNH)
Appetite decrease 9
Somnolence 19
Abdominal Pain 22
Vomiting 30
Dyspepsia 49
Dizziness 53
Nausea 55
-Cheng et al 2007 Psychopharmacology 194 197-209
  • Rare/black box warnings liver involvement ,

Medication management Titration
  • Systematic titration schedule
  • See Texas Algorithm approach (Pliszka et al)
  • Why?
  • Substantial variation in optimal response between
  • Assist in determination of optimal dose
  • Avoid under and over dosing
  • In contrast to treatment as usual which may
  • Typical try 1-2 dose and adjust over-time as
    prompted by parent (or teacher)
  • This is inadequate and will not likely lead to
    optimal medication choice or dose selection

You have to get follow-up school data
  • .parent reports of amount of change over time
    cannot serve as a substitute for an assessment of
    the amount of change that occurs in the
    classroom (Lavigne et al., 2012 p. 341)
  • Although it may be difficult and time-consuming,
    gathering teacher reports appears to be critical
    for the optimal treatment of ADHD (Lavigne et
    al., 2012 p. 341)

Time point Scale correlation ( variance)
Pre-treatment 0.199 (3.96)
4 months 0.331 (11.0)
12 months 0.405 (16.4)
Parent-teacher correlations on ADHD symptoms in a
primary care treatment study (Lavigne et al.,
Medication treatment example (1)
Medication treatment example (2)
Medication treatment example (3)
Medication treatment example (4)
Medication management Maintenance
  • Maintenance/Long-term treatment
  • Chronic disorder
  • Less developed protocols for chronic treatment
  • Typical recommendation
  • At least a brief trial off once a year to
    reassess benefits
  • Dose adjustment may be required over time
  • Long-term maintenance likely low
  • Monitor height and weight
  • Long-term risks
  • Maybe stature
  • Long-term benefits
  • May reduced drug abuse (or not)
  • Academic benefits not clear

  • Medication Questions?
Evidenced-based psychological interventions
  • Behavioural parent training
  • Well-established
  • School-based behavioural interventions
  • Well-established

(Pelham et al., 1998 Chronis et al, 2006)
Parent Behavioural Training
  • Parenting practice as a focus of treatment
  • though not etiologic, poor practices may worsen
    course, improved practices may improve function
  • Typical components in evidence-based
  • Review video-taped models
  • Practice through role-playing
  • Homework assignments
  • Explicit multi-step curriculums
  • Individual explicit curriculum
  • E.g., Barkley Parent Training Program
  • Group-based
  • E.g., Incredible Years (Webster-Stratton)

Examples of behavioural-based parenting techniques
  • Teach positive reinforcement skills
  • Positive attending and ignoring skills during
    special time
  • Attending positively to appropriate independent
    play and compliance with simple requests
  • Use of reward oriented home token/point system
  • Response cost for non-compliance and rule
  • Time-out from reinforcement

Parent Behavioural Caveats
  • Interventions are easier said than done
  • Doesnt mean parenting caused ADHD
  • Not all parent training programs are
    evidence-based or effective
  • Should have specific curriculum, with specific
    skill development using evidence-based
    strategies, modeling, homework, etc. (organized
    with multiple sessions)
  • Different than a parent support group
  • Not adequate for improving school behaviour
  • Uptake completion can be poor

School-based interventions
  • Antecedent-based strategies
  • Consequent-based strategies
Antecedent-based strategies (DuPaul, Weyandt,
Janusis, 2011)
  • Antecedents environmental events that precede
    (and may trigger) specific behaviour
  • Examples of antecedent strategies
  • Post and strategically review classroom rules
  • Pair with more frequent praises when rules
  • Reduce task demand by reducing length or content
    of assignment
  • Giving task choice for assignment
  • However still aimed at developing skill

Consequence-based strategies(DuPaul, Weyandt,
Janusis, 2011)
  • Consequences manipulation of environmental
    events following a specific behavior (to alter
    frequency of that behaviour)
  • Examples of consequence-based strategies
  • Response Cost
  • E.g., token reinforcers are removed contingent on
    disruptive, off-task behaviour
  • Contingent positive reinforcement
  • Praise
  • Token economy
  • Daily Behavioural Report Card

What is a DBRC?
  • AKA home-school notes
  • A mechanism to document behaviour, give feedback,
    and intervene
  • Some key components of DBRC
  • Specification of clear target behaviour(s)
  • Periodic judgment about behaviour on simple scale
  • System of daily monitoring
  • Communication component between teacher and home
  • May be delivered as a one piece of multicomponent
  • Effectiveness indicated in recent meta-analysis
    (Vannest et al, 2010)

Problems with some positive reinforcement efforts
implement in schools
  • Relying on written recommendations or a single
    consultation session likely inadequate
  • Lack of understanding of underlying behavioural
  • E.g., reinforcement of escape behaviour
  • Premature discontinuation of attempt
  • Lack of adjustment in targets/rewards over time
  • Lack of tracking progress over time

A small pilot attempt
  • The Good Behavioural Card Program (GBCP)
  • A collaborative effort within the COPE program
GBCP - Structure
  • Modeled on the Daily Behavioural Report Card from
    the University of Buffalo
  • Provide an initial 4 consultation sessions with
    teacher and parent of identified student
  • Introduction packets given to parents and
  • Outline of program, examples given, request
    homework to generate initial ideas (targets and
  • 1st session
  • Develop clear target goals, and reward structure,
    schedule follow-up
  • 2nd -4th session
  • review progress, modify target goals rewards as
    needed, troubleshoot
  • Extend if needed and progress anticipated

Daily Good Behaviour Card
Childs name
Target Goals Target Goals Period 1 Period 2 Period 3
1 Quietly Raising Hand
2 Starting Assignment
3 Keep on Working
A home reward is earned if child gets at least
________________ Teachers signature
Today, child earned ____

__________________ Parents signature

Parent to check box if a home reward received
Good Behavioural Card Program Teacher Tracking
Goal 1 (modified) Quietly Raising Hand Hand Child will raise his hand and not blurt out during group activities. This will be monitored on three occasions per day. If chidl can accomplish this task with less than 2 warnings/reminders he will receive 1 smiley point. This will be repeated on three separate occasions each day. The teacher will provide child feedback after each occasion and provide the smiley face if successful. (The modification is to drop from less than 3 to less than 2 warnings). Goal 2 Starting Assignment child will produce at least one sentence for writing projects on three occasions per day. If child can accomplish this task with less than 3 warnings/reminders then he will receive 1 smiley point for each of the three occasions. The teacher will provide child feedback after each occasion and provide the smiley face if successful. Goal 3 Keep on Working If the teacher catches child persisting or finishing a writing task (after above initiation), she will give him a point (smiley face). The teacher can provide one reminder if he is not demonstrating the behavior when she does her first follow-up check on him. There will be 3 different occasions during the day (lining up with the same periods as for Goal 2). He can earn a smiley face for each of these, i.e., up to 3 points/day. Total for the day If child gets at least 5 out of 9 total for the day he is eligible for a home reward. (Also, child is eligible for an in-school reward after every 3 smiley faces he receives in a given day 5 minute computer time)
Todays date Summary of success with Goal 1 Note down total number of smiley faces per day on this goal (out of total of 3) Summary of success with Goal 2 Note down total number of smiley faces per day on this goal (out of total of 3) Summary of success with Goal 2 Note down total number of smiley faces per day on this goal (out of total of 3) Total for the day Note down total number of smiley faces for the day (Goal 1 Goal 2 Goal 3) (Total possible 9)

Combined Treatment
  • Meds Beh
  • Mixed results as to whether combination superior
    to medication
  • MTA study
  • Combination treatment was not superior to
    medication alone overall
  • However, medication doses lower in group
    receiving the combination treatment
  • Some sub-groups (co-morbid disorders) may do
    better with combination treatment
  • May depend on outcome measure
  • Apparent biases against behavioural component in
    design, measurement and reporting (Pelham, 1999)
  • Maybe a serial approach

Selective sequencing and combinations
  • 1. Behavioural modification first
  • Add medication for residual if necessary
  • Possibly at lower doses
  • 2. Medication first
  • Add behavioural modification for residual if
  • 3. Simultaneous use
  • may not be needed expensive difficult
    evaluating dosing/components

Academic Interventions
  • Changing the classroom environment
  • Moving students desk away from others/closer to
  • Closed classrooms
  • Structure/routine
  • Visual aids
  • Task instructional modifications
  • Reduce task length
  • Divide tasks into subunits
  • Goal setting
  • Shorter time intervals
  • Increased stimulation on tasks
  • Computer-assisted instruction
  • Highlight essential material
  • Multiple sensory modalities
  • Dividing content material into smaller chunks
  • Provide immediate feedback
  • Game-like format

Focusing on Success Teaching Children with
ADHD http//
Alternative/complementary options
  • Consider extent of evidence
  • Most marketed A/C strategies have little to no
    scientific evidence
  • Possible exception, omega 3 fatty acids
  • E.g., RCT of eicosapentanenoic acid (EPA)
  • Gustafsson 2010
  • While not total overall ADHD score improvement,
    teacher inattention ratings significantly better
    subgroup with ODD better vs. placebo
  • E.g., Omega-3 Fatty Acid, meta-analysis
  • Bloch Qawasmi, 2011
  • 10 trials with 699 children
  • Small but significant effect for ADHD symptoms

Questions about interventions
A few links
  • AAP 2011 guidelines
  • http//
  • Make sure to look at the supplement
  • Children and Adults with ADHD
  • US
  • Canada
  • The Canadian Attention Deficit Hyperactivity
    Disorder Resource Alliance
  • http//

  • Subcommittee on ADHD (2011) ADHD Clinical
    practice guidelines for the diagnosis,
    evaluation, and treatment of attention-deficit/hyp
    eractivity disorder in children and adolescents.
    Pediatrics http//
  • American Psychiatric Association (1994)
    Diagnostic and Statistical Manual of Mental
    Disorders IV
  • American Psychiatric Association (2010) DSM-5
    Options Being Considered for ADHD.
  • Block M Qawasmi (Sept 2011, in press) Omega-3
    fatty acid supplementation for the treatment of
    children with attention-deficit/hyperactivity
    disorder symptomatology systematic review and
    meta-analysis. JAACAP
  • Cherkasova M, Hechtman L (2009) Neuroimaging in
    attention-deficit/hyperactivity disorder beyond
    the frontostriatal circuitry. Can J of Psychiatry
    54(10) 651-664.
  • Chronis A et al (2006) Evidence-based
    psychosocial treatments for children and
    adolescents with attention-deficit/hyperactivity
    disorder. Clinical Psychology Review 26
  • Coghill D, Sonuga-Barke E (2012) Annual research
    review Categories versus dimensions in the
    classification and conceptualisations of child
    and adolescent mental disorders implications of
    recent empirical study. Journal of Child
    Psychology Psychiatry 53(5) 469-489.
  • Epstein J et al (2008) Community-wide
    intervention to improve the attention-deficit/hype
    ractivity disorder assessment and treatment
    practices of community physicians. Pediatrics
    122 19-27

  • Gustafsson P et al (2010) EPA supplementation
    improves teacher-rated behaviour and oppositional
    symptoms in children with ADHD. Acta Paediatrica
    99 1540-9.
  • Lavigne J et al (2012) Can parent reports serve
    as a proxy for teacher ratings in medication
    management of ADHD? Journal of Developmental
    Behavioural Pediatrics 33336-342
  • Leslie L et al (2004) Implementing the American
    Academy of Pediatrics Attention-Deficit/Hyperactiv
    ity Disorder Diagnostic Guidelines in Primary
    Care Settings. Pediatrics 114 (1) 129-140.
  • MTA Cooperative Group (1999). A 14-month
    randomized clinical trial of treatment strategies
    for attention-deficit/hyperactivity disorder.
    The MTA Cooperative Group. Multimodal Treatment
    Study of Children with ADHD. Archives of General
    Psychiatry 56 1073-86.
  • McBurnett K et al (2001) Symptom properties as a
    function of ADHD type An argument for continued
    study of sluggish cognitive tempo. Journal of
    Abnormal Child Psychology 29(3) 207-213.
  • Pelham W et al (1998) Empirically supported
    psychosocial treatment for attention deficit
    hyperactivity disorder Journal of Clinical Child
    Psychology 27190-205.
  • Pelham, W. E. (1999). The NIMH multimodal
    treatment study for attention-deficit
    hyperactivity disorder just say yes to drugs
    alone? Canadian journal of psychiatry, 44(10),
  • Pliszka et al. (2006) The Texas Childrens
    Medication Algorithm Project Revision of the
    Algorithm for Pharmacotherapy of
    Attention-deficit/Hyperactivity Disorder.
    Texas algorithm project 45(6) 642-657.

  • Pliszka et al (2007) Practice parameters for the
    assessment and treatment of children,
    adolescents, and adults with attention-deficit/hyp
    eractivity disorder. Journal of the American
    Academy of Child and Adolescent Psychiatry
  • Polanczyk MD, de Lima MD, Horta MD, Biederman MD,
    Rohde MD. The Worldwide Prevalence of ADHD A
    Systematic Review and Metaregression Analysis. Am
    J Psychiatry. 2007 Jun 1164(6)9428.
  • Schab D, Trinh N (2004) Do articifical food
    colors promote hyperactivity in children with
    hyperactive symdromes? A meta-analysis of double
    blind placebo controlled trials. Devp Beh
    Pediatrics 25(6) 423-434
  • Shaw P et al (2007) Attention-deficit/hyperactivit
    y disorder is characterized by a delay in
    cortical maturation. Proceedings of the National
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