Attention Deficit Hyperactivity Disorder (ADHD)


Article Author:
Warren Magnus
Saad Nazir
Arayamparambil Anilkumar


Article Editor:
Kamleh Shaban


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/17/2019 7:17:02 AM

Introduction

Attention Deficit-Hyperactivity Disorder (ADHD) is a psychiatric condition that has long been recognized as affecting children's ability to function. Individuals suffering from this disorder show patterns of developmentally inappropriate levels of inattentiveness, hyperactivity, or impulsivity. Although there used to be two different diagnoses of Attention Deficit Disorder vs Attention Deficit Hyperactivity Disorder, the DSM IV combined this into one disorder with three subtypes: predominantly inattentive, predominantly hyperactive, or combined type. 

The symptoms begin at a young age and usually include lack of attention, lack of concentration, disorganization, difficulty completing tasks, being forgetful, and losing things. These symptoms should be present before the age of 12, have lasted six months, and interfere with daily life activities in order to be labeled as 'ADHD'. This must be present in more than one setting (ie at home and at school, or at school and at afterschool activities). It can have large consequences including social interactions, increased risky behaviors, loss of jobs, and difficulty achieving in school. 

ADHD must be considered within the context of what is developmentally and culturally appropriate for a person. It is considered a dysfunction of executive functioning, predominantly a frontal lobe activity. Therefore, patients with ADHD show disability not only in attention and focus but also in decision making and emotional regulation. Children with ADHD can have difficulty with social interactions, can be easily frustrated, and can be impulsive. They are often labeled as "trouble makers." 

ADHD is not a new condition and has been called different names throughout history. It was labeled as 'minimal brain dysfunction' in the 1930s and has ever since changed names to ADD and ADHD respectively.[1] Its prevalence has increased over time, with a seeming spike in the 1950s as school became more standardized for children. 

It is important to diagnose and treat the disorder at a young age so that the symptoms do not persist into adulthood and cause other comorbid conditions. The treatment for the disorder is mostly related to stimulants and psychotherapy.[2] This review would further shed light upon the causal factors, pathophysiology, and management of ADHD.

Etiology

The etiology of ADHD is related to a variety of factors that include both a genetic and an environmental component. It is one of the most heritable condition in terms of psychiatric disorders. There is a much greater concordance in monozygotic twins than dizygotic. Siblings have twice the risk of having ADHD than the general population. Similarly, viral infections, smoking during pregnancy, nutritional deficiency and alcohol exposure in the fetus have also been explored as possible causes of the disorder. There are no consistent findings on brain imaging of patients with ADHD. The number of dopaminergic receptors has also been implicated in the development of the disorder whereby research has shown that the receptors are decreased in the frontal lobes in individuals with ADHD.[3][1] There is also evidence for the role of noradrenergic receptor involvement in ADHD. 

Epidemiology

The subtypes of attention deficit disorders are found to have a different rate of prevalence in a group of individuals suffering from the disorders. It is found that the inattentive subtype is prevalent in about 18.3% of the total patients while hyperactive/impulsive and combined represent 8.3% and 70% respectively. It is also found that the inattentive subtype is more common amongst the female population. The disorders (collectively) are found in a 2:1 male to female ratio as per different researches.[4] It is prevalent in around 3%-6% of the adult population.[5] It is one of the most prevalent disorders found in childhood. There is some evidence that ADHD is more prevalent in the United States than in other developed countries. 

Pathophysiology

ADHD is associated with cognitive and functional deficits that relate to diffuse abnormalities in the brain. The anterior cingulate gyrus and dorsolateral prefrontal cortex (DLFPC) are found to be small in individuals who are suffering from ADHD. It is thought that these changes account for the deficits in goal-directed behavior. Moreover, activity in the frontostriatal region is also reduced in these individuals as measured by fMRI. It is important to understand these pathophysiological mechanisms so that the pharmacotherapy is directed onto them.[6] It is important to remember that ADHD is a clinical diagnosis. There are no standard laboratory or imaging results among patients with ADHD. 

History and Physical

In order to diagnose ADHD, it is very important to take a relevant history of the concerned individual.  ADHD is diagnosed in children based upon their history where the children face difficulty in at least 6 of the 9 symptoms as mentioned in DSM V. Inattentive symptoms include: not paying close attention to tasks, missing small details, rushing through tasks, not seeming to listen when spoken two, difficulty organizing things, not finishing work, dislikes or avoids tasks that take sustained mental effort, losing thins, or being forgetful. Hyperactive symptoms include: fidgeting, feeling like an "internal motor" is always going, leaving their seat, climbing on things, being loud, blurting out answers, talking excessively or out of turn, having trouble waiting their turn, interrupts or intrudes on others. These symptoms must be present in multiple settings.

In adults, however, these core symptoms may be missing and they may manifest as other problems such as procrastination, mood instability, and low self-esteem. They will likely be more impulsive in nature, or inattentive, as the hyperactivity symptoms can be better controlled. The symptoms of inattention or hyperactivity will likely be elicited when doing a proper history of childhood but may have been missed. 

ADHD interferes with functioning and development. This can be included in adults who do not work and is often dismissed in this population. For example, a stay at home mom may have difficulty getting her children to school on time, organizing her home, paying attention while driving, etc, that affect her functioning and daily life even though she is not at work or at school. It is important to take this into consideration when making a diagnosis. 

Different scales are used to measure the problems that patients with ADHD are suffering from. One such example is of the Brown Attention Deficit Disorder Scale which includes common areas that these individuals face difficulty in and can be used in adults to identify the disorder. For children, the Vanderbilt ADHD scale is often used as it has both a teacher and parent component. A physical examination, on the other hand, is not as useful in the diagnosis of ADHD but it can still be used to exclude medical causes such as thyroid problems. It could also help to identify any medical issue that could thereby direct the treatment options. For example, individuals with hypertension may not opt for stimulants as a treatment option.[7][8][9]

Evaluation

ADHD is a disorder that is diagnosed clinically and does not have any specific laboratory or radiologic tests. The neuropsychological tests are not as sensitive for diagnosing the disorder and hence the disorder should be diagnosed based upon the history of the patient.[7] The evaluation of the patient with ADHD is usually done with different rating scales and multiple informants which may include the teachers and parents. It is necessary for a clinician to look for other disorders as they may be a cause for the symptoms that a child is exhibiting. It should not be diagnosed in the context of symptoms from another disorder, for example, a psychotic episode or manic episode.

DSM V: types of ADHD

  1. Predominantly inattentive
  2. Predominantly impulsive or hyperactive
  3. Combination of the above
  • The onset is usually before age 12
  • Symptoms present at school, work or home
  • The disturbance causes significant impairment in social, occupational and academic functioning
  • The disorder is not accounted for by any other behavior disorder

Treatment / Management

Pharmacological therapy remains the mainstay of treatment for patients suffering from ADHD. It is divided into two major categories which fall into stimulants or non-stimulants. Stimulants are further broken into amphetamines and methylphenidates. Both types of stimulants block the reuptake of dopamine at the presynaptic membranes and postsynaptic membranes. Amphetamines also directly release dopamine. Stimulants are the mainstay of treatment for ADHD. They are effective in about 70% of patients. There is a number needed to treat of 2. There are multiple formulations of each subtype of stimulants including immediate release and extended release, long-acting, or sustained release. Side effects of stimulants include changes in blood pressure, decreasing appetite and sleep, and risk of dependency. However, there is an increased risk of substance use in patients with ADHD and studies show treating with a stimulant decreases their overall lifetime risk of substance abuse. Because stimulants are controlled substances, providers often are hesitant to use them. However, repeated evidence has shown how imperative it is to try stimulants in ADHD. 

Of the non-stimulant option, there are also two types: antidepressants and alpha agonists. Within the antidepressant category, atomoxetine is is the best known, and works as a selective norepinephrine reuptake inhibitor. It is known to be effective in many trials as a treatment option for ADHD, though not nearly as effective as stimulants. It also has minimal antidepressant effects. It is often used in children who don't tolerate stimulants or have anxiety. Other antidepressants include bupropion, which targets dopamine and serotonin, and TCAs which are the last choice options. These work by targeting norepinephrine.

Lastly, alpha agonists such as clonidine and guanfacine can be used as an effective treatment for ADHD. However, these are associated with multiple cardiovascular effects like lowering blood pressure, sedation (clonidine more than guanfacine), weight gain, dizziness, etc. They are found to be more effective in younger children than adults.[6] 

Psychosocial treatment is the other form of treatment that is used for individuals suffering from the disorder. This form of treatment includes psycho-education for the family and patient and cognitive behavioral training programs designed specifically for the patient to achieve short and long term goals. Research has found that these training programs prove to be very effective when used along with the pharmacotherapy. However, unlike other psychiatric disorder, there is strong evidence for medication management without therapy as being the most efficacious. [10][11][12]

The FDA has just approved the trigeminal nerve stimulation system for children not on medications. The device generates a low-level electrical pulse which suppresses hyperactivity.

There is no diet that has been found to improve ADHD

Differential Diagnosis

It is important to differentiate ADHD from other clinical disorders as it can have symptoms that may overlap with them. Mood disorders such as depression and anxiety can be misdiagnosed in a patient with ADHD as these symptoms (inattention and poor focus, memory loss, distractibility, etc) generally persist in individuals with the disorder. Substance abuse disorders should also be carefully examined as children with ADHD are prone to substance abuse. It is important to rule out hearing disorders, learning disorder, and developmental disorders from ADHD. [6]

Prognosis

The prognosis of ADHD is variable depending upon the age of the individual who is experiencing the symptoms. It is seen that the symptoms of ADHD persist into the teenage years and may involve the social and academic domains of life. Two-fifths of the patients continue experiencing the symptoms in the teenage years whereas a quarter of them are also diagnosed with a concurrent antisocial disorder. However, an important trend in the long term was also noted whereby the symptoms of the patients with ADD decreased in adulthood by about 50%. The general rule of thumb is that 50% of patients "grow out of" ADHD, especially with treatment, and another 25% do not need treatment into adulthood. This is theorized twofold; first that stimulants help improve the development of the frontal lobe over time, and second that adults often choose careers that don't require sustained attention. In adulthood, these patients are able to achieve their educational and vocational goals.[13]

Treatment of ADHD has also been shown to improve symptoms of the oppositional defiant disorder and conduct disorder. It has shown a decreased risk of substance use. 

However, untreated ADHD can cause persisting dysfunction and devastating consequences included but not limited to long term inability to work, increased car accidents, and increased substance abuse. [14][15]

Deterrence and Patient Education

It is important that patients with ADHD are followed up regularly to check upon their symptoms and comorbidities. In order to achieve treatment goals, the role of patient education cannot be emphasized enough. For children who suffer from ADHD, the parents should be formally educated about the disorder so that they understand the concept behind the diagnosis. Medication treatment can only be optimized if there is ongoing interaction between the primary caregiver and the family.[16]

Pearls and Other Issues

ADHD is often a very easily treated disorder that is highly stigmatized in society. Proper diagnosis and treatment can change the lives of patients who suffer from these

Providers should not be hesitant to try stimulant medications. They are highly effective and can be very safe when properly prescribed

ADHD has multiple comorbidities including anxiety, depression, and conduct disorder. Treatment of ADHD can improve the symptoms of these other disorders

Enhancing Healthcare Team Outcomes

ADHD is a condition that can be managed but the protocols for managing it must be followed effectively in order to achieve a fruitful result. The management involves an interprofessional team that includes the specialist psychiatrist, pediatrician, pharmacist, and other health care professionals including nurse practitioners who help in diagnosing the disorder. The collaboration on part of the family and the health care team becomes important so as to know the exact history of the events that the patient has gone through.

The team should then make up a management plan that may include a pharmacologic treatment, a psychosocial intervention or both. The comorbid disorders of ADHD would have to be analyzed by the team as depression and anxiety disorders are much more common in this set of population.  In order to make a diagnosis of ADHD, regular follow-ups with the primary caregiver of the child should be scheduled along with the child. The clinician can then ascertain and evaluate the child himself and clinically co-relate it to the findings as provided by the caregiver. This can further be taken to a specialist psychiatrist whereby a confirmatory diagnosis can be made. This would then involve a set of other health-care professionals such as a psychologist or a trained psychotherapist along with the psychiatrist. The treatment plan is then formulated by the team and the caregiver himself is given an important role along with the healthcare team. The caregiver has to observe the patient and help in noticing the changes that the child may exhibit. It can be hence concluded that an integrated healthcare plan should be followed for the diagnosis and treatment of ADHD so that the long term goals of the treatment can be achieved. (I) [17]

Open communication between the interprofessional team is the key to improve outcomes. The team should have a conference as that everyone knows what message is to be sent to the caregiver, who often get upset with mixed messages.

Outcomes

Despite decades of research, the outcomes for patients with ADHD are guarded. Noncompliance with medications is common and follow is difficult as many patients seek alternative treatments. Many parents do not trust the drugs and often seek alternative care. There is no question that currently available treatments do help some patients improve functionally but without treatment, the individuals continue to deteriorate and eventually end up in financial, legal and social difficulties.[4][18][19]


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Attention Deficit Hyperactivity Disorder (ADHD) - Questions

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Parents of a 9 year old bring their son in for treatment of severe ADHD. They were advised by his teacher to get him on medication. The parents agree there is a problem but request alternative treatment. Which of the following is the best management?



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An 8 year old is having problems with focus at school. The parents say the teacher reports he disrupts the class and the patient says he hates math and social studies. The parents don't feel there is a problem and the father states the same things were said about him in school. Now he is a successful salesman. Which of the following would be the best management?



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A 10-year-old boy is brought in by his parents as his school performance has deteriorated over the past two years. His teacher states that he will not sit in his seat and disrupts the class by talking. He is not completing his assignments at school or his homework. Birth history and development were normal. Physical exam including neurological exam is normal. The child is cooperative but fidgets. Select the most likely diagnosis.



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A patient is attending occupational therapy as part of a partial hospitalization mental health program finds it difficult to concentrate due to crowded conditions. What would be the best environmental strategy to allow the patient to do problem-solving tasks?



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While evaluating a patient with ADHD an OT should be aware of:



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When evaluating an adult's attention during a craft activity, on which of the following should the OT focus?



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A patient with traumatic brain injury is working with an OT group but instead of staying with his task he spends much of time watching the patient next to him work. This probably indicates an issue with:



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An OT is working with a child with ADHD, hyperactive type on improving attention span. The activity is a jigsaw puzzle with many pieces. When confronted with the task the child pushes them off the table and throws them around. Which of the following would restructure the activity to improve the chance of success?



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A patient with mental illness has been hired for a clerical position but is worried that easy distractibility may affect her job performance. Select the most appropriate intervention.



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A school based occupational therapist is asked to improve the environment for students with ADHD. Select the best adaptation that would improve learning but not affect other students.



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An 8-year-old child is having difficulties remaining seated during class. She wiggles and stands, disrupting the class. The child receives assistance with special education and after school attends a sensory integration program. Which of the following would help the child remain focused?



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Which of the following is least likely in a child with attention-deficit/ hyperactivity disorder?



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Select the incorrect statement about attention deficit hyperactivity disorder (ADHD).



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A young boy has decreased attention span, normal intelligence, and hyperactivity. Which of the following would be an appropriate medication?



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The mother of a 6-year-old reports that her son has been doing poorly at school and is easily distractible. For the past year, he has been talking more, interrupts, and has difficulty sitting still. His teacher has said that he has poor concentration for activities that need mental effort. Which of the following is the most likely diagnosis?



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A 7-year-old boy with attention-deficit/hyperactivity disorder (ADHD) is started on methylphenidate but does not respond. Which of the following could be the next step?



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Which region of the brain is noted to have decreased activity on functional neuroimaging in patients with attention deficit hyperactivity disorder?



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A 6-year-old girl is brought to a child and adolescent mental health practitioner because she is constantly in trouble at school for not paying attention, blurting out answers in class, and disrupting other students. This is starting to interfere with her keeping friends at school because she is always in trouble with the teacher. During the exam, the child fidgets with everything and is "bouncing off the walls" with energy. The same behaviors are present at home and at church according to the mother. Her language and motor skills are appropriate. Psychoeducational testing was done and she has no learning disorder. Which of the following is the most likely diagnosis?



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Which of the following is true regarding attention-deficit hyperactivity/disorder (ADHD) in the pediatric population?



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Which treatment is used for attention-deficit/ hyperactivity disorder?



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Which is not part of the diagnosis of attention deficit hyperactivity disorder?



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A 10-year-old boy is started on methylphenidate for attention-deficit/hyperactivity disorder (ADHD). Select the incorrect statement about treating this condition.



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A 5-year-old is brought in for evaluation at the recommendation of his teacher. He has some developmental delays, but the major issue is that he is not able to sit still and is very active. His favorite activities are video games and watching cartoons. Which of the following would not be part of the initial assessment?



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A 5-year-old boy in kindergarten is evaluated with the Conner Scales and it indicates that he is oppositional and hyperactive. His behavior is impacting him at school and at home. Which of the following is not an initial step in management?



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A 5-year-old boy is started on stimulant medication for ADHD and oppositional problems. He has improvement in attention and sitting still but gets into fights on the playground during recess. Which of the following would be least useful in determining whether changes in medications are needed?



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A 6-year-old in first grade is on stimulant medication for attention-deficit/hyperactivity disorder (ADHD) and has a developmental language disorder. At the end of the year, the teacher feels he will not be able to read and should not be in a regular classroom. Which of the following is the least preferable strategy?



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Which of the following behavioral inventories would not be used with a 7-year-old with possible problems with learning and attention at school?



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A mother of a child with ADHD is concerned that food additives and sugar are the cause of his problems. Select the least useful intervention.



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A 7-year-old presents with a 6-month history of trouble organizing tasks and activities, being easily distracted, talking excessively, and squirming in his seat. He has had interventions with behavioral techniques with minimal results. Which medication would be considered first-line treatment?



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Select the condition that would not improve long-term success in children with attention and learning disorders.



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A 7-year-old boy is brought to the office as the parents have concerns about his behavior and performance in school over the past 6 months. His teacher has noticed that he is disruptive in class, cannot sit still at his desk, inappropriately blurts out answers to questions without being on, and has difficulty staying on task to complete his daily assignments. His performance on school exams has dropped, which the teacher believes to be due to making more careless mistakes. Also, his hockey coach has reported that he often cannot wait his turn in line during drills. Which of the following is the best next step in management of this patient?



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A caregiver brings a child to the pediatric clinic to investigate a statement made by the teacher suggesting that the child has attention-deficit/hyperactivity disorder. Which of the following signs and symptoms are consistent with this diagnosis? Select all that apply.



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A 16-year-old male presents with a decline in performance at the school. He complains of irritability, lack of concentration, and restlessness. He describes his mood as being 'down,' but he relates that to his performance in school. Upon further questioning, it is confirmed that the child was never a bright student in the school, but his performance was up to par earlier. He does not have any suicidal tendencies, but he believes he is let down by his actions. Which of the following is the next step of management?



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Attention Deficit Hyperactivity Disorder (ADHD) - References

References

Cortese S,Coghill D, Twenty years of research on attention-deficit/hyperactivity disorder (ADHD): looking back, looking forward. Evidence-based mental health. 2018 Nov     [PubMed]
Matas M, Approach to attention deficit disorder in adults. Canadian family physician Medecin de famille canadien. 2006 Aug     [PubMed]
Pary R,Lewis S,Matuschka PR,Rudzinskiy P,Safi M,Lippmann S, Attention deficit disorder in adults. Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists. 2002 Jun     [PubMed]
Millichap JG, Etiologic classification of attention-deficit/hyperactivity disorder. Pediatrics. 2008 Feb     [PubMed]
Salvi V,Migliarese G,Venturi V,Rossi F,Torriero S,Viganò V,Cerveri G,Mencacci C, ADHD in adults: clinical subtypes and associated characteristics. Rivista di psichiatria. 2019 Mar-Apr     [PubMed]
Kates N, Attention deficit disorder in adults. Management in primary care. Canadian family physician Medecin de famille canadien. 2005 Jan     [PubMed]
Wilens TE,Spencer TJ, Understanding attention-deficit/hyperactivity disorder from childhood to adulthood. Postgraduate medicine. 2010 Sep     [PubMed]
Weiss M,Murray C, Assessment and management of attention-deficit hyperactivity disorder in adults. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2003 Mar 18     [PubMed]
Geffen J,Forster K, Treatment of adult ADHD: a clinical perspective. Therapeutic advances in psychopharmacology. 2018 Jan     [PubMed]
Mannuzza S,Klein RG, Long-term prognosis in attention-deficit/hyperactivity disorder. Child and adolescent psychiatric clinics of North America. 2000 Jul     [PubMed]
Brinkman WB,Hartl Majcher J,Poling LM,Shi G,Zender M,Sucharew H,Britto MT,Epstein JN, Shared decision-making to improve attention-deficit hyperactivity disorder care. Patient education and counseling. 2013 Oct     [PubMed]
Kaur P,Sharma M, Diagnosis of Human Psychological Disorders using Supervised Learning and Nature-Inspired Computing Techniques: A Meta-Analysis. Journal of medical systems. 2019 May 28;     [PubMed]
Huguet A,Izaguirre Eguren J,Miguel-Ruiz D,Vall Vallés X,Alda JA, Deficient Emotional Self-Regulation in Children with Attention Deficit Hyperactivity Disorder: Mindfulness as a Useful Treatment Modality. Journal of developmental and behavioral pediatrics : JDBP. 2019 May 22;     [PubMed]
Han DH,McDuff D,Thompson D,Hitchcock ME,Reardon CL,Hainline B, Attention-deficit/hyperactivity disorder in elite athletes: a narrative review. British journal of sports medicine. 2019 May 16;     [PubMed]
Ching C,Eslick GD,Poulton AS, Evaluation of Methylphenidate Safety and Maximum-Dose Titration Rationale in Attention-Deficit/Hyperactivity Disorder: A Meta-analysis. JAMA pediatrics. 2019 May 28;     [PubMed]
Steingard R,Taskiran S,Connor DF,Markowitz JS,Stein MA, New Formulations of Stimulants: An Update for Clinicians. Journal of child and adolescent psychopharmacology. 2019 Apr 30;     [PubMed]
van der Burg D,Crunelle CL,Matthys F,van den Brink W, Diagnosis and treatment of patients with comorbid substance use disorder and adult attention-deficit and hyperactivity disorder: a review of recent publications. Current opinion in psychiatry. 2019 Apr 16;     [PubMed]
Mikami AY,Miller M,Lerner MD, Social functioning in youth with attention-deficit/hyperactivity disorder and autism spectrum disorder: transdiagnostic commonalities and differences. Clinical psychology review. 2019 Mar;     [PubMed]
Leahy LG, Diagnosis and treatment of ADHD in children vs adults: What nurses should know. Archives of psychiatric nursing. 2018 Dec;     [PubMed]

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