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Attention Deficit Hyperactivity Disorder (ADHD)
OverviewAttention deficit hyperactivity disorder (ADHD) is a chronic neurobehavioral disorder that begins in childhood and is characterized by some combination of hyperactivity, impulsivity, and/or inattention. These symptoms are present to such a degree that they significantly interfere in at least 2 areas of the child's life, such as in the home and classroom. Three major types of ADHD are currently recognized (predominantly inattentive, predominantly hyperactive-impulsive, and combined). Growing evidence suggests that at least one subtype of ADHD is caused by defects in the dopamine and norepinephrine transporter proteins within the nerve cell wall. [Vaidya: 2008] [Kollins: 2008] [Kim: 2006]
ADHD is a disorder that can be treated safely and with good efficacy. If undertreated or left untreated, it carries significant morbidity including an increased risk of substance abuse in adolescents. [Wilens: 2008] [Biederman: 2009] Some children who do not meet full criteria for diagnosis could respond to behavioral intervention and school support, and should not be treated with medications. [Wolraich: 2011] Children with ADHD often are affected by other conditions including emotional or behavioral disorders, developmental disabilities, and other medical conditions. [Wolraich: 2011]
Other Names & Coding
Attention deficit disorder
F90.0, predominantly inattentive type
F90.1, predominantly hyperactive-impulsive type
F90.2, combined type
ICD-10 Coding for ADHD provides further coding details.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [American: 2013] generally designates the same codes as ICD-10 does, but its publisher, the American Psychiatric Association, prohibits our including their codes or descriptions.
PrevalenceADHD is one of the most common chronic disorders of childhood. Approximately 7% of children in the U.S. meet criteria for ADHD diagnosis. [Wolraich: 2011] Boys are more than twice as likely as girls to have received a diagnosis of ADHD. [Visser: 2014]
GeneticsAlthough ADHD clearly runs in families, and twin and adoption studies support a strong genetic component, the genetic mechanisms are not yet well understood. [Smith: 2009] [Faraone: 2005] Markers on at least 7 chromosomes and genes for dopamine and serotonin receptors, transporters, and associated enzymes have been found to be statistically associated with ADHD. Environmental factors are also shown to play a role in some cases. [Pliszka: 2007]
PrognosisMany children show improvement in adolescence, yet individuals may need support and treatment for this condition through adulthood. [Shaw: 2012]
Practice Guidelines
Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M,
Stein MT, Visser S.
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.
Pediatrics. 2011;128(5):1007-22. PubMed abstract / Full Text
Roles of the Medical HomeMost children with ADHD can be treated by their medical home provider without subspecialty consultation or referral. Occasionally, additional expertise that includes psychologists, behavioral/developmental pediatricians, child psychiatrists, and educational specialists, may be needed, particularly if the child has a co-morbid condition. Even if children are referred elsewhere for diagnosis, ongoing evaluation and management should still be performed within the context of the medical home, and children with ADHD should be considered to have special health care needs. [Wolraich: 2011]
Ongoing communication with the child's parents and teachers is essential for appropriate management. Periodic visits, in addition to well-child exams and acute-care visits, are generally needed to discuss status and manage medications. The AAP suggests that the medical home should:
- Monitor and update family knowledge and understanding of ADHD.
- Offer counseling on the family's response to the condition.
- Provide developmentally appropriate education for the child about ADHD and updates as the child grows.
- Be available to answer the family's questions.
- Ensure coordination of health and other services.
- Help families set specific goals in areas related to the child's condition and its effects on daily activities.
- When appropriate, connect families with other families who have children with similar chronic conditions.
Clinical Assessment
Pearls & Alerts for AssessmentInattentive type may go undiagnosed
Children with inattentive presentation may go undiagnosed for longer than the hyperactive/impulsive presentation, presumably because the symptoms are less bothersome to others. Among girls, the inattentive type is more common, and may present simply as poor school performance that worsens when higher-level problem solving is required, typically in upper elementary grades.Discrepancy between family and teacher symptom assessments
When ratings of ADHD symptoms differ, additional sources, such as former teachers and coaches, may be helpful. Also consider the setting: A teacher in a very structured classroom may not note symptoms that are easily observed in a less structured classroom, or in a busy home. A child who expends a lot of effort to pay attention and behave appropriately at school may "fall apart" at home, and this can result in more severe parent ratings.Re-evaluation needed
Frequent re-evaluation to prevent under treatment may be needed. [Wolraich: 2011]Cardiac screening before stimulant use
The American Heart Association proposes that all children being prescribed ADHD medications should first be screened for heart disease with echocardiogram and/or electrocardiogram. The AAP recommends screening only when heart disease is suspected by a physician.ADHD and autistic spectrum disorder
Children with autism may present with symptoms of ADHD during early elementary school, or earlier. If earlier, it may be difficult to differentiate from the autism symptoms. Children with autism spectrum disorder who present with significant hyperactivity, inattention, or impulsivity, despite adequate supports, should be evaluated for co-morbid ADHD.
For the ConditionEvaluation for ADHD should be initiated if the child presents with inattention, hyperactivity, impulsivity, low school achievement for the child's IQ, and/or behavior problems. [Wolraich: 2011] The evaluation will generally take a few visits and will require gathering information about school performance, school/daycare behavior, and functioning within the family and with friends by using specific ADHD checklists. Many of these checklists also screen for additional problems, such as defiant behavior and learning concerns. It should be recognized that these measures are subject to the biases of the people completing them. Specific ADHD checklists include:
- Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) ( 1.1 MB): Forms for initial and follow-up assessments for teacher and parent informants. Includes scoring instructions, no fee required.
- NICHQ Vanderbilt Assessment Scale - Parent Informant - Online Version (Spanish) ( 3.9 MB) and NICHQ Vanderbilt Assessment Follow-Up - Parent Informant - Online Version (Spanish) ( 3.6 MB): Spanish (with English translation) forms for assessing and quantifying the impact of attention problems at home. Includes scoring instructions, no fee required.
- Conners 3rd Edition: Administered to parents and teachers of children and adolescents 6–18 years old; self-report, 8–18 years old. Available for a fee.
- ADHD Rating Scale-5 for Children and Adolescents: Containing 18 items, the scale is linked directly to DSM-IV diagnostic criteria for ADHD. Available for a fee.
Periodic repetition of behavior scales completed by parents and teachers can be helpful to track response to medication and behavioral interventions. These are often completed every 6-12 months. It is important to pick a time during the school year when the teacher has had some exposure to the student. Subjective reports can also be very helpful.
For ComplicationsIf treatment does not seem to be effective, consider using a validated screening tool to identify and help diagnose co-morbid conditions, such as anxiety, depression, oppositional-defiant disorder, conduct disorder, substance use or abuse, learning disorders, mood disorders, language disorders, sleep problems including sleep apnea, tics, other neurological disorders including autism, and trauma.
The following screening tools may be helpful:
- Screen for Child Anxiety Related Disorders (SCARED) (University of Pittsburgh) ( 218 KB): Child self-assessment with 41 (brief) questions that have fill-in circles for possible answers. Contains scoring information, no fee required.
- Pediatric Symptom Checklist (PSC) and Youth Report (Y-PSC) ( 47 KB): Psychosocial screen to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a 35-item checklist for parents or youth to complete, and scoring instructions. No fee required.
- Patient Health Questionnaire-9 (PHQ-9) ( 40 KB): Nine-question depression screen with scoring information that can be used with adolescents. Questions are based on DSM-IV diagnostic criteria for major depressive disorder, no fee required.
- Severity Measure for Depression - Ages 11–17 ( 228 KB): Adolescent-focused, 9-question, depression screen with scoring information. No fee required.
- Center for Epidemiological Studies Depression Scale for Children (CES-DC) ( 37 KB): Depression screening tool, with 20 questions, that takes about 10 minutes to complete. No fee required.
- DSM-5 Parent-Rated Level 1 Symptom Measure—Age 6–17 (APA) ( 367 KB) and DSM-5 Self-Rated Level 1 Symptom Measure—Age 11–17 (APA) ( 250 KB): Free, 25-question assessments for initial patient interview and for monitoring treatment progress. Includes scoring instructions.
- Achenbach System of Empirically Based Assessment (ASEBA): A variety of screening tools are available for a fee. (Child Behavior Checklist (CBCL))
- SEEK Parent Screening Questionnaire (PSQ-R): Parent questionnaire that screens for child maltreatment and toxic stress using 15 yes/no questions; free to download in English, Chinese, Spanish, and Vietnamese.
- Behavior Assessment System for Children, Third Edition (BASC-3): Screen for children 2-21 years of age that takes about 15 minutes to complete; available for purchase.
- Car, Relax, Alone, Friends, Forget, Trouble (CRAFFT 2.1): A 6-question behavioral health screening tool recommended by the American Academy of Pediatrics' Committee on Substance Abuse to screen adolescents for high-risk alcohol and other drug use disorders. Available for free download in 13 languages.
PresentationsPresentation may vary considerably based on form of ADHD (predominantly inattentive, predominantly hyperactive-impulsive, combined), developmental age, severity, environment, co-morbid conditions, and other factors. Young children with the inattentive type may have significant difficulty attending to the reading of a picture book, whereas adolescents may have difficulty finishing homework and performing required tasks. Inattentive students may not be noticed until they start falling behind in school, often in the upper elementary grades when problem solving becomes more complex.
Preschoolers with the hyperactive/impulsive type may be constantly physically active, running in circles, and climbing on furniture, whereas adolescents with this type may engage in risky behaviors and sports. Hyperactive children are typically noticed earlier due to disrupting their classrooms or getting into trouble at home.
It is important to consider developmental age when deciding whether the level of inattentiveness and/or hyperactivity is abnormal. A child with the cognitive level of a 5-year-old, although he may be twice that age, usually has the activity level and attention span of a 5-year-old. It is also important to take a history about the symptoms over time, as children who start out with symptoms of hyperactivity in preschool may present with more inattentive/impulsive symptoms in adolescence.
Diagnostic CriteriaWhen DSM-5 was updated in 2013, minor changes were made to diagnosis criteria for ADHD, including onset of symptoms before age 12 instead of age 7, and fewer symptom criteria needed to diagnose adolescents than children. (See ADHD Fact Sheet (APA) ( 279 KB) for 2 pages of DSM-5 updates.)
DSM-5 Criteria for ADHD
People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Based on types of symptoms, 3 presentations of ADHD can occur:
- Predominantly inattentive presentation: Six or more symptoms of inattention (listed below) for children up to age 16, or 5
or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they
are inappropriate for developmental level:
- Fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities
- Has trouble holding attention on tasks or play activities
- Does not seem to listen when spoken to directly
- Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked)
- Has trouble organizing tasks and activities
- Avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period (such as schoolwork or homework)
- Loses things necessary for tasks and activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)
- Is easily distracted
- Is forgetful in daily activities
- Predominantly hyperactive-impulsive presentation: Six or more symptoms of hyperactivity-impulsivity (listed below) for children
up to age 16, or 5 or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present
for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level:
- Fidgets with or taps hands or feet, or squirms in seat
- Leaves seat in situations when remaining seated is expected
- Runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless)
- Is unable to play or take part in leisure activities quietly
- Is "on the go" acting as if "driven by a motor"
- Talks excessively
- Blurts out an answer before a question has been completed
- Has trouble waiting his/her turn
- Interrupts or intrudes on others (e.g., butts into conversations or games)
- ADHD combined type: If enough symptoms of both inattention and hyperactivity-impulsivity criteria were present for the past 6 months
- Several inattentive or hyperactive-impulsive symptoms were present before age 12 years
- Several symptoms are present in 2 or more settings (e.g., at home, school or work; with friends or relatives; in other activities)
- There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning
- The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
Clinical ClassificationPresentations: [American: 2013]
- ADHD predominantly inattentive presentation
- ADHD predominantly hyperactive-impulsive presentation
- ADHD combined type
- Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning.
- Moderate: Symptoms of functional impairment between "mild" and "severe" are present.
- Severe: Many symptoms in excess of those required to make diagnosis, or severe symptoms that are particularly severe and result in marked impairment in social or school functioning.
Differential DiagnosisOther diagnoses that should be considered are listed below:
- Seizures/Epilepsy, particularly Childhood Absence Epilepsy
- Hearing Loss and Deafness, including middle ear infections causing hearing loss or auditory processing disorder, may contribute to inattention. Evaluation for hearing deficits should be triggered by any suspicious symptoms or findings.
- Sleep Issues may cause daytime difficulties, such as hyperactivity and inattention. Consider further evaluation if history and physical exam (e.g., large tonsils) suggest obstructive sleep apnea.
- Visual impairment, including visual processing disorders may present as inattention. An ophthalmological exam is warranted if there is any concern, or if the child has any difficulty passing screening tests.
- Tourette Syndrome could lead to speaking out inappropriately or repetitive noises, which could be confused with the impulsiveness or repetitive noises seen with ADHD.
- Learning disabilities may be the etiology of poor school performance and may accompany ADHD. If these are a concern, refer for psychological testing. Children with learning disabilities will often score significantly higher on IQ testing compared to achievement testing.
- Depression or anxiety are similar psychiatric problems that may occur with ADHD or cause symptoms of ADHD that may resolve when the primary disorder is treated. If concerned, consider a referral to child psychiatry or psychology. Ask about life changes causing anxiety or difficulty concentrating, such as a parent's death, divorce, etc.
- Autism Spectrum Disorder may present like ADHD, including difficulties with focus on non-preferred activities. Children with ADHD may also present with social skill deficits. [Kotte: 2013] ADHD and autism spectrum disorder may be genetically linked. [Rommelse: 2010]
- Substance Use Disorders
- Side effects of medication
- Trauma/childhood adverse events can lead to hypervigilance and arousal that can be mistaken for ADHD, or can overlap with actual ADHD. [Kaya: 2008] Screening for adverse events in childhood can help in the differential diagnosis as well as provide insight into ways to tailor support for struggling families. See Toxic Stress Screening and the Foster Care module for more information.
Medical Conditions Causing ConditionMedical conditions causing ADHD include:
- Fetal alcohol spectrum disorders
- Traumatic Brain Injury or post-concussive attention problems
- Hyperthyroidism
Comorbid & Secondary ConditionsCo-morbid conditions include:
- Tourette Syndrome
- Oppositional Defiant Disorder/Conduct Disorder and ADHD
- Anxiety Disorders and Attention Deficit Hyperactivity Disorder (ADHD)
- Mood Disorders and ADHD
- Specific Learning Disability (SLD) and ADHD
- Coordination Disorders and ADHD
- Lack of improvement in behavioral symptoms despite appropriate treatment and services for ADHD
- Persistent school underachievement or school avoidance
- Parental concern for a comorbid condition
- Low self-esteem, anxiety, irritability, sleep disturbance, or sadness
- Negative/oppositional behaviors
- Substance Use Disorders
History & Examination
Current & Past Medical HistoryTake a full medical history that includes heart problems, and motor and vocal tics. Ask about:
- Previous illnesses or accidents that may contribute to attention problems
- Recent medical problems, growth, appetite, and possible side effects of medication for ADHD
- Mood, interactions with peers
- Adherence to prescribed medication or therapies
- Staring, brief eye-blinking, or other automatisms - consider absence seizures if "spacing out" events are occurring multiple times per day with a clear interruptions of activity, such as speaking, walking, or drinking
- Sleep onset and duration, as well as the presence of snoring or restless sleep
- Toileting and elimination
Family HistoryAsk about a family history of ADHD, associated conditions, cardiovascular disease, sudden death, and mental health disorders including bipolar disorder and psychosis. Growing evidence suggests that risk of cardiovascular disease and sudden cardiac death is extremely low with the use of both stimulant and non-stimulant ADHD medications. [Martinez-Raga: 2013]
Pregnancy/Perinatal HistoryAsk about any pregnancy or perinatal problems that may contribute to poor intellectual and behavioral functioning.
Developmental & Educational ProgressAssess developmental milestones and intellectual and social functioning in family and day care or school settings. Assessment should include documentation of:
- ADHD DSM-5 criteria by parent interview or by use of a specific checklist, such as the Vanderbilt ADHD Parent Rating Scale ( 72 KB)
- Specific symptoms by use of a checklist, such as Vanderbilt ADHD Teacher Rating Scale ( 53 KB)
- Age at which the problem behaviors began, the settings in which the behaviors occur, and to what degree the child is impaired by the symptoms
Age and interest level will affect children's ability to attend to tasks; video games and other highly stimulating activities are not good indicators of a child's ability to attend.
Be sure to inquire about fine and gross motor skills, as many children with ADHD have poor coordination and possibly a developmental coordination disorder. [Wolraich: 2011]
Social & Family FunctioningInquire about:
- Recent changes in the family that may be causing anxiety or depression
- Behavior and functioning within the family and elsewhere (e.g., church or during extracurricular activities)
- Consistency or changes of medication
- Use of complementary/alternative treatments
- Parenting challenges
Physical Exam
Vital SignsHR | RR | BP - Resting tachycardia or hypertension may indicate hyperthyroidism or another hypermetabolic state that may present with hyperactivity. Increased heart rate may occur with stimulant use; however, hypertension is less likely to occur as a result of medication use. [Hailpern: 2014] Use of alpha agonists such as guanfacine or clonidine can lower blood pressure and can cause rebound hypertension if discontinued abruptly. [Committee: 2001]
Growth ParametersHt | Wt | BMI - Because stimulant medications may cause appetite suppression, follow weight closely. Although stimulants may slow height to some extent when first started, this effect appears to decrease over time. Recent studies have found that use of stimulants by children does not prevent them from obtaining their full adult height [Harstad: 2014]; it is still prudent to regularly measure children's height and weight while on medications.
HEENT/OralCheck for middle ear fluid, which, if persistent, may cause conductive hearing loss. Assess tonsillar size and potential for obstruction and sleep disturbance. Also, check thyroid size, consistency.
Laboratory TestingLab testing is not indicated unless there are specific concerns from the medical history, such as lead exposure or symptoms of hyperthyroidism. Consider checking ferritin as a marker of iron deficiency, as this can be associated with disordered sleep, which in turn can negatively impact daytime attention and behavior. [Abou-Khadra: 2013] [Cortese: 2009] If malnutrition is suspected to play a role in the child's performance, specific nutritional markers could be tested as well.
ImagingRarely, children with absence epilepsy may present with ADHD signs. EEG is necessary only if there is a clear pattern of seizures.
Other TestingTesting for intelligence: Usually performed by the school, an IQ test, such as the Wechsler Intelligence Scale for Children [WISC], and a learning disability test, such as the Woodcock-Johnson, may be helpful when there seems to be a discrepancy between ability and performance.
Echocardiogram and EKG: In 2008, the American Heart Association recommended that all children being prescribed ADHD medications should first be screened for heart disease with echocardiogram and/or electrocardiogram. [Vetter: 2008] However, the 2011 clinical practice guidelines published by the AAP recommends using clinical judgment regarding screening when there are cardiac symptoms, or there is a significant cardiac or sudden death history in the family. [McPherson: 2004] See Stimulants and Cardiovascular Monitoring (AAP) for further discussion.
Specialty Collaborations & Other Services
Developmental - Behavioral Pediatrics (see ID providers [2])
Consult for expert assessment in diagnosing complicated cases, such as for discriminating symptoms related to developmental delay, or for diagnosis of younger children.
Psychiatry/Medication Management (see ID providers [23])
Consult to help with diagnosis and management of situations complicated by underlying medical issues, such as a history of traumatic brain injury, co-morbid psychiatric conditions such as mood or anxiety disorders, or for children who fail to respond to standard therapies.
General Counseling Services (see ID providers [206])
This category includes all types of counselors/counseling for children. Once on the page, the search can be narrowed by city or using the Search within this Category field.
Neuropsychiatry/Neuropsychology (see ID providers [3])
Consult when full psychological testing is not available through the school district or if learning disabilities are suspected. May also be helpful in designing and implementing behavioral plans and therapies.
Pediatric Cardiology (see ID providers [4])
Consult if there are concerns about a child's cardiac status that would affect treatment and management decisions.
Treatment & Management
OverviewManagement principles vary with the age of the individual: [Wolraich: 2011]
- Preschool age children (4-5years old) should first receive parent- and/or teacher-administered behavior therapy. If this is not successful and function continues to be moderately to severely impaired, methylphenidate may be considered.
- For school-aged children 6-11 years old, behavior therapy and school placement optimization, plus stimulants, or to a lesser extent atomoxetine, extended-release guanfacine, and extended-release clonidine are recommended.
- For adolescents, similar treatments are recommended, but the consent of the individual should be obtained before medicating. Long-acting guanfacine, atomoxetine, or clonidine, or stimulants that have lower abuse potential, such as lisdexamfetamine (Vyvanse), OROS extended-release methylphenidate (Concerta), or dermal methylphenidate may be preferred. [Wolraich: 2011]
Consider using a validated screening tool to identify and help diagnose co-morbid conditions. See Screening for Co-Morbid conditions, above, for screening tools. The following Portal pages provide diagnosis and management information for co-morbid conditions and ADHD:
Pearls & Alerts for Treatment & ManagementStimulant use & cardiac events
AAP guidelines indicate that evidence does not clearly demonstrate an increased risk of serious cardiovascular events, such as MI, QT prolongation, sudden death, or ventricular arrhythmias, in children using stimulant medication.Tics, Tourette syndrome, and stimulant use
Recent studies suggest that use of stimulants and other psychotropic medications for ADHD do not increase tics in most people and may reduce tics.Stimulant drug misuse
Frequent or early requests for stimulant refills may suggest misuse. Prescribers should carefully monitor their prescription refill requests.
Pharmacy & Medications
Prescribers should carefully monitor their prescription refill requests; frequent or early requests for stimulant refills may suggest misuse. Stimulants with relatively less abuse potential include lisdexamfetamine (Vyvanse), methylphenidate patch (Daytrana), or OROS extended-release methylphenidate (Concerta). Non-stimulant medications, such as atomoxetine (Strattera), extended-release clonidine (Kapvay), and guanfacine (Intuniv) may also be considered.
Extended-release guanfacine, extended-release clonidine, and atomoxetine offer alternatives for treatment. The AAP recommends their use if stimulants (one from each class) have been tried and are not successful. Atomoxetine is a selective norepinephrine reuptake inhibitor, and can cause nausea and sleepiness. Guanfacine and clonidine are norepinephrine receptor type alpha 2 agonists that can cause sedation and hypotension (more so in clonidine), and both are available in short and long-acting formulations. These medications need to be used on a daily basis without medication holidays. Extended-release guanfacine and clonidine have been shown to have efficacy as add-on therapies with stimulants. These non-stimulant medications for ADHD can take several weeks for full effect.
Side effects for both classes of stimulant medications include mild stomachaches and headaches, depressed appetite and weight loss, difficulty sleeping, increased blood pressure and heart rate, and irritability/anxiety. Cautions and contraindications to stimulant use include presence of a cardiac abnormality or condition; significant side effects (e.g., decreased appetite, insomnia, and poor growth); and significant tic exacerbation. (See Pearls and Alerts section, above.) Rare side effects can also occur; the FDA warns that methylphenidates and atomoxetine can cause priapism, and that atomoxetine can cause suicidality. Rarely, psychiatric symptoms, such as manic symptoms, paranoia, and hallucinations may occur. For more information, see FDA Drug Safety Communication: Safety Review Update of Medications used to treat Attention-Deficit/Hyperactivity Disorder (ADHD) in children and young adults.
Effects of stimulants on co-morbid conditions needs further study. Some of what is known is as follows:
- Cardiac problems: Stimulant drug packaging includes the following statement, "Stimulant products generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug." The AAP and AHA offer further insights into medication use in these special groups. [AAP: 2008] [Perrin: 2008]
- Fetal alcohol spectrum disorders (FASD): Children with FASD often have problems with attention and impulsivity; stimulant treatment may help, or it could make symptoms worse.
- Tics/Tourette syndrome: FDA package labeling for stimulants indicates that tics are a contraindication to use of these medications, so use of stimulants for children with tics is considered "off-label." However, recent studies suggest that use of stimulants and other psychotropic medications for ADHD do not increase tics in most people and may reduce tics. [Tourette's: 2002] [Roessner: 2006] Untreated ADHD may be more troubling to the child than the tics themselves. [Erenberg: 2005] However, monitoring of tics before and after starting stimulants is warranted due to individual variation. [Tourette's: 2002] For more information about relevant studies, see [Murphy: 2013] and [Pringsheim: 2011].
- Autism: Children with autism spectrum disorder have a decreased response rate to ADHD medications and an increased rate of reported side effects. Despite these concerns, recent information suggests that medication may be helpful. Cautious monitoring for unexpected effects on the child's functioning (e.g., an increase in anxiety symptoms) should be maintained. [Posey: 2007]. There is growing evidence that ADHD and autism spectrum disorder may be linked genetically. [Rommelse: 2010] See Evaluation and Medication Choice for ADHD Disorder Symptoms in Autism Spectrum Disorders (AAP) for treatment of co-morbid ADHD and autism spectrum disorder. [Mahajan: 2012]
- Other neurologic conditions: ADHD symptoms are often observed in children with neurologic conditions, such as neural tube defects, muscular dystrophy, cerebral palsy, intellectual disability, and various genetic syndromes. Stimulants are often helpful for these symptoms in children with intellectual disability [Aman: 2003], but not necessarily in children with velocardiofacial syndrome (22q11.2 Deletion Syndrome). [Antshel: 2007] Treatment for ADHD symptoms in neurologic and other conditions should be accompanied by close monitoring to assure response and limit side effects.
Off-label medications are occasionally used to manage ADHD, particularly in patients with comorbidities, such as depression, include bupropion (Wellbutrin), modafinil (Provigil or Nuvigil), and tricyclic antidepressants, such as desipramine (Norpramin) and imipramine (Tofranil). [American: 2013]
Medication tables with dosing information for stimulants and non-stimulants can be found at:
- Under-treatment - Medications should be titrated to maximum doses without adverse side effects instead of relying on milligram-per-kilogram recommendations to ensure adequate treatment of symptoms.
- Noncompliance with medication - This may be more common in families where parents also have symptoms of ADHD. [Wolraich: 2011]
- A co-morbid condition
Specialty Collaborations & Other Services
Developmental - Behavioral Pediatrics (see ID providers [2])
Consult for guidance on managing more complex cases, such as for children who have comorbid conditions, intellectual disability, or difficult-to-treat ADHD.
Psychiatry/Medication Management (see ID providers [23])
Consult to help with diagnosis and management of situations complicated by underlying medical issues.
Mental Health/Behavior
Most children with ADHD respond to more structure and fewer distractions in the environment. Behavior management takes advantage of this and includes the use of time-outs, a token economy, and daily school report cards while teaching the parents to respond consistently to a child's misbehavior. For instance, when a child comes home from school, a parent should inquire about homework, set a time and place for the child to do the homework, keep external noise (e.g., television) to a minimum, and then check that the homework is completed. Parents should be reminded that the long-acting preparations of stimulant medication are beginning to wear off in the afternoon, and homework attempted sooner rather than later, will probably be more successful. Classes are often available locally, through school systems, mental health, or other agencies, to train parents in achieving the goals of directed supervision and in managing behavioral problems.
Before starting medications, work with parents and school to identify 3 to 6 target behaviors or outcomes based on the needs and strengths of the child. The goals should be realistic and measurable. These may include: [Wolraich: 2011]
- Improvements in relationships with parents, siblings, teachers, and peers
- Decreased disruptive behaviors
- Improved academic performance, particularly in volume of work, efficiency, completion, and accuracy
- Increased independence in self-care or homework
- Improved self-esteem
- Enhanced safety in the community, such as in crossing streets or riding bicycles
The medical home should then collaborate with the family to develop a comprehensive treatment plan, which might include stimulant medication and behavioral management, as well as treatment of associated conditions.
Specialty Collaborations & Other Services
General Counseling Services (see ID providers [206])
This category includes all types of counselors/counseling for children. Once on the page, the search can be narrowed by city or using the Search within this Category field.
Pediatric Neurology (see ID providers [2])
Referral may be helpful in managing ADHD, particularly if there are concerns about head injury or other neurologic conditions, such as seizures.
The school will usually conduct an evaluation to determine if the child qualifies for special education services. If so, the school, with parental input, will develop an individualized education program (IEP). If the child does not qualify for special education services, he or she may qualify for a 504 plan for children with disabilities.
The medical home may be involved in planning and evaluating the child's school services. Direct communication is often very helpful for both the provider and the school. A signed consent from the parents should be in place before these conversations or meetings take place.
Teachers can help the child with ADHD by setting clear goals, decreasing distractions, offering subtle reminders to stay on task, and providing more structure. A daily or weekly "report card" or "contract" system with positive reinforcement for reaching goals can also help. For some children, a 504 plan may provide for desired classroom adaptations, such as preferential seating and decreased workload. See Education & Schools in the Portal's For Physicians & Professionals section for more detail on IEPs and 504 plans. Letter Requesting Assessment from Teacher (AAP) is a sample of a request for a teacher to complete a behavior assessment for their student. ADHD for Educators may also be helpful.
Parents should be encouraged to meet with the child's teacher early in the year to discuss the child's diagnosis, needs, and what has worked or failed in the past. This is particularly true if the family is changing school districts or if the child is transitioning to middle or high school. Ongoing meetings, not necessarily at the time of parent-teacher conferences, may also be helpful. Families should know that many colleges and universities have programs to support students with various disabilities through their years in higher education.
Specialty Collaborations & Other Services
School Districts (see ID providers [116])
The medical home provider can work with the school to ensure appropriate services are provided to qualifying students, as well as to obtain periodic feedback on how treatment interventions are affecting the child's school participation and performance. Contact the district officials if the school is unable or unwilling to offer needed services. The child's family should authorize a release of information to allow two-way communication between the school and the physician's office.
Funding & Access to Care
Specialty Collaborations & Other Services
Medical Care Expense Assistance (see ID providers [65])
There are a variety of organizations that either provide health care or help find or fund it.
Health Insurance Counseling and Advocacy (see ID providers [21])
Organizations that can help families find insurance and healthcare options based on their individual situations.
CHIP, State Children's Health Insur Prog (see ID providers [21])
The Children's Health Insurance Program, or CHIP, is a state health insurance plan for children. Depending on income and family size, working Utah families who do not have other health insurance may qualify for CHIP.
Medicaid (see ID providers [65])
A combined federal and state program administered by the state that provides medical benefits for individuals and families with limited incomes who fit into an eligibility group that is recognized by federal and state law.
Prescription Drug Patient Assistance Programs (see ID providers [49])
Many organizations can provide information on and links to prescription assistance programs, or discounts and/or support toward prescription costs.
Financial Assistance, Other (see ID providers [110])
Local and national organizations and programs can help families receive financial support to help with their child's chronic conditions.
Complementary & Alternative Medicine
Food elimination diets are controversial. Mainstream western medicine tends to discount this approach, indicating that only a few individuals may benefit from specific food elimination diets. However, analysis of the 2011 Impact of Nutrition on Children with ADHD (INCA) study suggests that a strictly supervised food elimination trial may be an approach to consider; use of IgG blood levels to prescribe diets is not advised, though. [Pelsser: 2011] European guidelines would indicate no evidence for elimination diets unless there are GI symptoms. There is some evidence for removal of dyes.
Dr. Sanford Newmark, a physician at the UCSF Pediatric Integrative Neurodevelopmental Clinic, in his presentation at the 2014 AAP National Conference, recommended these safe mind-body approaches to help with attention and self-regulation: yoga, exercise (martial arts), EEG neurofeedback, and a healthy diet consisting of whole grains, fruits and vegetables, and lean protein sources. Less well studied is adherence to organic diets. Avoidance of unnecessary food dyes and chemicals and maintaining fairly even blood sugar and insulin levels by eating frequent, smaller meals with complex carbohydrates and healthy proteins and fats, are reasonable approaches. Although there is some support for use of neurofeedback for ADHD, this therapy is often not covered by insurance, has significant out-of-pocket expenses for the family, and its effects are not maintained once treatment has been discontinued. There is evidence to support use of high dose omega-3 and omega-6 fatty acids for treatment of ADHD, although the effect seen was not as great as with treatment with stimulants.
For a more in-depth review of dietary approaches to managing ADHD, see The Diet Factor in ADHD (AAP) and Complementary Medicine and ADHD (Medscape), which is available with from Medscape with a free account.
Issues Related to Attention Deficit Hyperactivity Disorder (ADHD)
Clinical AssessmentCoordination Disorders and ADHD
Learning/Education/SchoolsSpecific Learning Disability (SLD) and ADHD
Mental Health/BehaviorAnxiety Disorders and Attention Deficit Hyperactivity Disorder (ADHD)
Mood Disorders and ADHD
Oppositional Defiant Disorder/Conduct Disorder and ADHD
Ask the Specialist
Although clinical practice guidelines recommend starting with stimulant medications for first-line therapy, when would you be more likely to treat with something else first (and what would you use)?
The alpha 2 agonists can be very useful in children with developmental disabilities, such as autism spectrum disorder, because of a lower side effect profile and higher tolerability in children with co-morbid conditions like tics, anxiety, or sleep problems.
Which stimulant medications are the least likely to be abused or sold illegally?
Long-acting stimulant medications, such as Vyvanse and Concerta, have lower abuse potential because of their mechanism of release; the Daytrana patch is also a good stimulant option to use when there are concerns about abuse. Non-stimulant options, such as Intuniv, Kapvay, and Strattera, can also be useful when concerned about the potential misuse of stimulant medications.
Is there any special guidance on management of ADHD in children with autism?
Children with autism have a poorer response to stimulant medications with more side effects than typically developing children with ADHD. Starting with lower doses and titrating up slowly is very important in this group of patients. Non-stimulant medications, such as the alpha 2 agonists, may also be a good option. See the 2012 guidelines for treatment of ASD and ADHD at [Mahajan: 2012] for more information.
Why is my patient having such difficulty with tantrums? Should I be worried about an additional diagnosis?
If there are significant behavioral concerns despite adequate supports and/or medication management, it is important to consider additional or alternative diagnoses including oppositional defiant disorder, conduct disorder, mood or anxiety disorder, and autism spectrum disorder. However, children with ADHD can also have significant difficulties with executive functioning, which not only can affect organization and planning, but also can affect an individual's ability to shift between tasks, self-regulate, and adapt to new information or situations. Executive functioning skills only show mild improvement with medication management, and require behavioral interventions and supports.
My patient has been diagnosed with sensory processing disorder/sensory integration disorder, and has significant difficulties with attention and hyperactivity. Can this all be explained by the sensory processing disorder, or do they also have ADHD?
Although many children have sensory processing difficulties that affect their day-to-day lives, sensory processing disorder is not a recognized stand-alone diagnosis, and the AAP recommends screening for co-morbid conditions including autism spectrum disorder, ADHD, developmental coordination disorder, and childhood anxiety disorders. For a child that presents with sensory concerns and symptoms of ADHD, it is important to diagnose ADHD and address the sensory components as part of their behavior support. [Zimmer: 2012]
Resources for Clinicians
On the Web
National Resource Center on ADHD (NRC)
A clearinghouse for the latest evidence-based information on ADHD; funded by the Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities.
Attention-Deficit Hyperactivity Disorder, Fourth Edition: A Handbook for Diagnosis and Treatment
Presents extensive knowledge on the nature, diagnosis, assessment, and treatment of ADHD; by Barkley R (22018), published by the Guilford Press (4th. ed.).
Helpful Articles
PubMed search for ADHD in children, last 1 year.
Ghanizadeh A.
Atomoxetine for treating ADHD symptoms in autism: a systematic review.
J Atten Disord. 2013;17(8):635-40. PubMed abstract / Full Text
Humphreys KL, Eng T, Lee SS.
Stimulant Medication and Substance Use Outcomes: A Meta-analysis.
JAMA Psychiatry. 2013;70(7):740-9. PubMed abstract / Full Text
Mahajan R, Bernal MP, Panzer R, Whitaker A, Roberts W, Handen B, Hardan A, Anagnostou E, Veenstra-VanderWeele J.
Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder symptoms in autism spectrum disorders.
Pediatrics. 2012;130 Suppl 2:S125-38. PubMed abstract / Full Text
Moen MD, Keam SJ.
Dexmethylphenidate extended release: a review of its use in the treatment of attention-deficit hyperactivity disorder.
CNS Drugs. 2009;23(12):1057-83. PubMed abstract
Salmeron PA.
Childhood and adolescent attention-deficit hyperactivity disorder: diagnosis, clinical practice guidelines, and social implications.
J Am Acad Nurse Pract. 2009;21(9):488-97. PubMed abstract / Full Text
Warikoo N, Faraone SV.
Background, clinical features and treatment of attention deficit hyperactivity disorder in children.
Expert Opin Pharmacother. 2013. PubMed abstract / Full Text
Clinical Tools
Assessment Tools/Scales
Vanderbilt Assessment Scales - Parent and Teacher Initial and Follow-Up Scales with Scoring Instructions (NICHQ) ( 1.1 MB)
Helps to diagnose ADHD in children between the ages of 6 and 12; also screens for anxiety, depression, oppositional-defiant, and conduct disorders. Includes questionnaires for the initial and follow-up assessments for teachers and parents - and scoring instructions. No fee is required.
NICHQ Vanderbilt Assessment Scale - Parent Informant - Online Version (Spanish) ( 3.9 MB)
Spanish (with English translation) online fillable, self-calculating form for assessing and quantifying the impact of attention problems at home. Includes scoring instructions, no fee required; NICHQ
NICHQ Vanderbilt Assessment Follow-Up - Parent Informant - Online Version (Spanish) ( 3.6 MB)
Spanish (with English translation) follow-up forms for assessing and quantifying the impact of attention problems at home. Includes scoring instructions, no fee required; NICHQ
Conners 3rd Edition
Screens for ADHD and comorbid disorders such as oppositional defiant disorder and conduct disorder. Administered to parents and teachers of children and adolescents age 6-18 and self-report for youth ages 8-18, English and Spanish. Updated for DSM-5. Proprietary/for purchase.
ADHD Rating Scale-5 for Children and Adolescents
Child and adolescent versions with parent and teacher questionnaires, ages 5-17, the scales take <5 minutes to complete. Scoring is linked directly to DSM-5 diagnostic criteria for ADHD. Available for purchase.
Achenbach System of Empirically Based Assessment (ASEBA)
A variety of screening tools are available for a fee.
Screen for Child Anxiety Related Disorders (SCARED) (University of Pittsburgh) ( 218 KB)
A child (ages 8-18) and parent self-report with 41 questions paralleling the DSM-IV classification of anxiety disorders, including general anxiety disorder, separation anxiety disorder, panic disorder, and social and school phobia. Free to download, or link to on-line Excel worksheet that calculates the score. Translations in Arabic, Chinese, French, German, Italian, Spanish, Tamil (Sri Lanka), and Thai.
Center for Epidemiological Studies Depression Scale for Children (CES-DC) ( 37 KB)
Ages 12 to 18; 6th grade reading level; Spanish version available; 20 items, 5 to 10 minutes to complete. No fee required.
Severity Measure for Depression - Ages 11–17 ( 228 KB)
Adolescent-focused, 9-question, depression screen with scoring information. No fee required.
Patient Health Questionnaire-9 (PHQ-9) ( 40 KB)
Nine-question depression screen in many languages with scoring information that can be used with adolescents 13-17 years old. Questions based on DSM-IV diagnostic criteria for major depressive disorder. Select a language and "Go to Selected Screener" for a PDF download; developed with a grant from Pfizer Inc, no fee required.
Pediatric Symptom Checklist (PSC) and Youth Report (Y-PSC) ( 47 KB)
Psychosocial screen to facilitate the recognition of cognitive, emotional, and behavioral problems. Includes a 35-item checklist for parents or youth to complete, and scoring instructions. No fee required.
Behavior Assessment System for Children, Third Edition (BASC-3)
Screen for children 2-21 years of age that takes about 15 minutes to complete; available for purchase.
DSM-5 Parent-Rated Level 1 Symptom Measure—Age 6–17 (APA) ( 367 KB)
Free, 25-question assessment for initial patient interview and for monitoring treatment progress. Includes scoring instructions; American Psychiatric Association.
SEEK Parent Screening Questionnaire (PSQ-R)
Parent questionnaire that screens for child maltreatment and toxic stress using 15 yes/no questions. Scroll to bottom of the page for links to free to download in English, Chinese, Spanish, Swedish, and Vietnamese; from the University of Maryland, School of Medicine Department of Pediatrics.
Car, Relax, Alone, Friends, Forget, Trouble (CRAFFT 2.1)
The CRAFFT 2.0/2.1 is an updated substance use brief screening tool for use with youth ages 12-21 and is recommended by the American Academy of Pediatrics. A clinician-administered version and a self-report version are provided. The screen and scoring instructions are available in 17 languages and can be downloaded or printed for free upon request; Boston Children's Hospital and Harvard Medical School Teaching Hospital.
Clinical Checklists & Visit Tools
NICHQ Vanderbilt ADHD Primary Care Initial Evaluation Form ( 1.7 MB)
2-page evaluation template includes scoring for the initial Vanderbilts, plus checkboxes for relevant medical history, physical examination, diagnostic assessment and plan, and related screenings; American Academy of Pediatrics.
Medication Guides
ADHD Medication Tables ( 226 KB)
Medication tables with dosing information for stimulants and non-stimulants; Medical Home Portal, last updated April 2020.
Caring for Children With ADHD: A Practical Resource Toolkit for Clinicians, 3rd Ed. (AAP)
his framework of tools and forms, templates, scales, and coding references is a complementary resource to the 2019 American Academy of Pediatrics (AAP) Clinical Practice Guideline, to enable and empower the clinician to provide needed care to children with ADHD from birth to adulthood. Available for purchase from the AAP.
Bright Futures in Practice: Mental Health—Volume II, Tool Kit
Comprehensive set of tools for clinicians and families; addresses mental health in various pediatric age groups; includes a variety of resources, checklists, intake and assessment forms, and patient education materials.
Patient Health Questionnaire (PHQ) Screeners
Free screening tools to be used by clinicians to help detect mental health disorders: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4. All PHQ, GAD-7 screeners and translations are downloadable from this website and no permission is required to reproduce, translate, display, or distribute them.
Letter Requesting Assessment from Teacher (AAP)
Sample letter requesting that a teacher complete a behavior assessment for their student. The AAP suggests that a release of information form, signed by parent, accompanies this letter; American Academy of Pediatrics.
Patient Education & Instructions
ADHD: Parents' Medication Guide (AACAP) ( 1.1 MB)
Forty-five page booklet that helps youngsters and their families better understand the treatments for ADHD; prepared by the American Academy of Child & Adolescent Psychiatry and American Psychiatric Association (2013).
Resources for Patients & Families
Information on the Web
ADHD (MedlinePlus)
Provides links to high-quality sources of information about ADHD; a service of the National Library of Medicine and National Institutes of Health.
ADHD (HealthyChildren)
Links to more than 90 articles that discuss aspects of ADHD evaluation and management; developed by the American Academy of Pediatrics.
What is ADHD? (KidsHealth)
Health information for parents, kids, and teens. This is the parent's page on ADHD, see the tabs at the top for the pages focused on kids and teens; sponsored by Nemours Foundation.
The Diet Factor in ADHD (AAP)
A comprehensive overview of the role of dietary methods for treatment of children with ADHD when pharmacotherapy has proven unsatisfactory or unacceptable; American Academy of Pediatrics.
ADHD Information (AAP)
List of publications for parents of children with ADHD; American Academy of Pediatrics.
ADHD Information (NIMH)
Overview and links to more information from the National Institute of Mental Health
Early Behavior Therapy Found to Aid Children With A.D.H.D. (New York Times)
A news story about a new study that finds children with attention-deficit problems improve faster when the first treatment they receive is behavioral: New York Times, Feb.
National & Local Support
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
A national non-profit organization, with numerous local chapters, that provides education, advocacy, and support for ADHD; includes ADHD-focused e-learning trainings for parents and teachers, information, advocacy, and support, podcasts, newsletters, and more.
Understood for Learning & Attention Issues
An organization providing resources to parents and teachers of children with different learning styles and attention disorders as well as as an initiative to create inclusive workplaces, by developing and implementing best-in-class disability inclusion programs so they can hire, advance, and retain people with disabilities. The site includes a specific resources and support for young adults.
Mental Health Clinical Trials (NIMH)
Links to descriptions of clinical trials related to numerous mental health conditions, including ADHD, anxiety, and depression; National Institute of Mental Health.
Clinical Trials in ADHD (clinicaltrials.gov)
Trial listings for ADHD with "completed," "recruiting," and "active" status noted.
Services for Patients & Families in Idaho (ID)
|Service Categories
|# of providers* in:
|Other states (5) (show)
|CHIP, State Children's Health Insur Prog
|Developmental - Behavioral Pediatrics
|Family Counseling
|Financial Assistance, Other
|General Counseling Services
|Health Insurance Counseling and Advocacy
|Medical Care Expense Assistance
|Outpatient Mental Health Care
|Pediatric Cardiology
|Pediatric Neurology
|Prescription Drug Patient Assistance Programs
|Psychiatry/Medication Management
|School Districts
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
American Academy of Pediatrics/American Heart Association clarification of statement on cardiovascular evaluation and monitoring of children and adolescents with heart disease receiving medications for ADHD: May 16, 2008.
J Dev Behav Pediatr. 2008;29(4):335. PubMed abstract
Abou-Khadra MK, Amin OR, Shaker OG, Rabah TM.
Parent-reported sleep problems, symptom ratings, and serum ferritin levels in children with attention-deficit/hyperactivity disorder: a case control study.
BMC Pediatr. 2013;13:217. PubMed abstract / Full Text
Aman MG, Buican B, Arnold LE.
Methylphenidate treatment in children with borderline IQ and mental retardation: analysis of three aggregated studies.
J Child Adolesc Psychopharmacol. 2003;13(1):29-40. PubMed abstract
American Academy of Child & Adolescent Psychiatry and American Psychiatric Association.
ADHD: Parents' Medication Guide.
2013; 45. http://www.parentsmedguide.org/
American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, DSM-5.
Fifth ed. Arlington, VA: American Psychiatric Association; 2013. 978-0-89042-554-1
American Psychiatric Association: DSM-5 Task Force.
Diagnostic and Statistical Manual of Mental Disorders.
Fifth ed. The American Psychiatric Publishing; 2013. http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425...
Antshel KM, Faraone SV, Fremont W, Monuteaux MC, Kates WR, Doyle A, Mick E, Biederman J.
Comparing ADHD in velocardiofacial syndrome to idiopathic ADHD: a preliminary study.
J Atten Disord. 2007;11(1):64-73. PubMed abstract
Atkinson M, Hollis C.
NICE guideline: attention deficit hyperactivity disorder.
Arch Dis Child Educ Pract Ed. 2010;95(1):24-7. PubMed abstract / Full Text
Guidelines that the cover diagnosis, treatment, and management of ADHD; National Institute for Health and Care Excellence (UK).
Biederman J, Monuteaux MC, Spencer T, Wilens TE, Faraone SV.
Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study.
Pediatrics. 2009;124(1):71-8. PubMed abstract
An encouraging 10-year case-control study of how stimulant use for treatment of ADHD decreases risk of developing comorbid mood disorders as well as improves academic success.
Brimble MJ.
Diagnosis and management of ADHD: a new way forward?.
Community Pract. 2009;82(10):34-7. PubMed abstract
Chavez B, Sopko MA Jr, Ehret MJ, Paulino RE, Goldberg KR, Angstadt K, Bogart GT.
An update on central nervous system stimulant formulations in children and adolescents with attention-deficit/hyperactivity disorder.
Ann Pharmacother. 2009;43(6):1084-95. PubMed abstract
Committee on Children With Disabilities.
American Academy of Pediatrics: The continued importance of Supplemental Security Income (SSI) for children and adolescents with disabilities.
Pediatrics. 2001;107(4):790-3. PubMed abstract
Provides an excellent understanding of what SSI is, what it does, what children are likely to qualify, and what the basic application process is like. Knowing this information will greatly enhance your ability to help families get into the system quickly.
Cortese S, Konofal E, Bernardina BD, Mouren MC, Lecendreux M.
Sleep disturbances and serum ferritin levels in children with attention-deficit/hyperactivity disorder.
Eur Child Adolesc Psychiatry. 2009;18(7):393-9. PubMed abstract
Erenberg G.
The relationship between Tourette syndrome, attention deficit hyperactivity disorder, and stimulant medication: a critical review.
Semin Pediatr Neurol. 2005;12(4):217-21. PubMed abstract
Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P.
Molecular genetics of attention-deficit/hyperactivity disorder.
Biol Psychiatry. 2005;57(11):1313-23. PubMed abstract
Ghanizadeh A.
Atomoxetine for treating ADHD symptoms in autism: a systematic review.
J Atten Disord. 2013;17(8):635-40. PubMed abstract / Full Text
Ghuman JK, Arnold LE, Anthony BJ.
Psychopharmacological and other treatments in preschool children with attention-deficit/hyperactivity disorder: current evidence and practice.
J Child Adolesc Psychopharmacol. 2008;18(5):413-47. PubMed abstract
Hailpern SM, Egan BM, Lewis KD, Wagner C, Shattat GF, Al Qaoud DI, Shatat IF.
Blood Pressure, Heart Rate, and CNS Stimulant Medication Use in Children with and without ADHD: Analysis of NHANES Data.
Front Pediatr. 2014;2:100. PubMed abstract / Full Text
Harstad EB, Weaver AL, Katusic SK, Colligan RC, Kumar S, Chan E, Voigt RG, Barbaresi WJ.
ADHD, stimulant treatment, and growth: a longitudinal study.
Pediatrics. 2014;134(4):e935-44. PubMed abstract / Full Text
Humphreys KL, Eng T, Lee SS.
Stimulant Medication and Substance Use Outcomes: A Meta-analysis.
JAMA Psychiatry. 2013;70(7):740-9. PubMed abstract / Full Text
Kaya A, Taner Y, Guclu B, Taner E, Kaya Y, Bahcivan HG, Benli IT.
Trauma and adult attention deficit hyperactivity disorder.
J Int Med Res. 2008;36(1):9-16. PubMed abstract
Kim JW, Kim BN, Cho SC.
The dopamine transporter gene and the impulsivity phenotype in attention deficit hyperactivity disorder: a case-control association study in a Korean sample.
J Psychiatr Res. 2006;40(8):730-7. PubMed abstract
Kollins SH, Anastopoulos AD, Lachiewicz AM, FitzGerald D, Morrissey-Kane E, Garrett ME, Keatts SL, Ashley-Koch AE.
SNPs in dopamine D2 receptor gene (DRD2) and norepinephrine transporter gene (NET) are associated with continuous performance task (CPT) phenotypes in ADHD children and their families.
Am J Med Genet B Neuropsychiatr Genet. 2008;147B(8):1580-8. PubMed abstract
Kotte A, Joshi G, Fried R, Uchida M, Spencer A, Woodworth KY, Kenworthy T, Faraone SV, Biederman J.
Autistic traits in children with and without ADHD.
Pediatrics. 2013;132(3):e612-22. PubMed abstract / Full Text
Mahajan R, Bernal MP, Panzer R, Whitaker A, Roberts W, Handen B, Hardan A, Anagnostou E, Veenstra-VanderWeele J.
Clinical practice pathways for evaluation and medication choice for attention-deficit/hyperactivity disorder symptoms in autism spectrum disorders.
Pediatrics. 2012;130 Suppl 2:S125-38. PubMed abstract / Full Text
Martinez-Raga J, Knecht C, Szerman N, Martinez MI.
Risk of serious cardiovascular problems with medications for attention-deficit hyperactivity disorder.
CNS Drugs. 2013;27(1):15-30. PubMed abstract
McPherson M, Weissman G, Strickland BB, van Dyck PC, Blumberg SJ, Newacheck PW.
Implementing community-based systems of services for children and youths with special health care needs: how well are we doing?.
Pediatrics. 2004;113(5 Suppl):1538-44. PubMed abstract
Moen MD, Keam SJ.
Dexmethylphenidate extended release: a review of its use in the treatment of attention-deficit hyperactivity disorder.
CNS Drugs. 2009;23(12):1057-83. PubMed abstract
Murphy TK, Lewin AB, Storch EA, Stock S.
Practice parameter for the assessment and treatment of children and adolescents with tic disorders.
J Am Acad Child Adolesc Psychiatry. 2013;52(12):1341-59. PubMed abstract / Full Text
Pelsser LM, Frankena K, Toorman J, Savelkoul HF, Dubois AE, Pereira RR, Haagen TA, Rommelse NN, Buitelaar JK.
Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial.
Lancet. 2011;377(9764):494-503. PubMed abstract
Perrin JM, Friedman RA, Knilans TK.
Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder.
Pediatrics. 2008;122(2):451-3. PubMed abstract / Full Text
Pliszka S.
Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder.
J Am Acad Child Adolesc Psychiatry. 2007;46(7):894-921. PubMed abstract
Historical ADHD guideline from 2007.
Pliszka SR, Matthews TL, Braslow KJ, Watson MA.
Comparative effects of methylphenidate and mixed salts amphetamine on height and weight in children with attention-deficit/hyperactivity disorder.
J Am Acad Child Adolesc Psychiatry. 2006;45(5):520-6. PubMed abstract
Posey DJ, Aman MG, McCracken JT, Scahill L, Tierney E, Arnold LE, Vitiello B, Chuang SZ, Davies M, Ramadan Y, Witwer AN, Swiezy
NB, Cronin P, Shah B, Carroll DH, Young C, Wheeler C, McDougle CJ.
Positive effects of methylphenidate on inattention and hyperactivity in pervasive developmental disorders: an analysis of secondary measures.
Biol Psychiatry. 2007;61(4):538-44. PubMed abstract
Pringsheim T, Steeves T.
Pharmacological treatment for Attention Deficit Hyperactivity Disorder (ADHD) in children with comorbid tic disorders.
Cochrane Database Syst Rev. 2011(4):CD007990. PubMed abstract / Full Text
Roessner V, Robatzek M, Knapp G, Banaschewski T, Rothenberger A.
First-onset tics in patients with attention-deficit-hyperactivity disorder: impact of stimulants.
Dev Med Child Neurol. 2006;48(7):616-21. PubMed abstract
Rommelse NN, Franke B, Geurts HM, Hartman CA, Buitelaar JK.
Shared heritability of attention-deficit/hyperactivity disorder and autism spectrum disorder.
Eur Child Adolesc Psychiatry. 2010. PubMed abstract
Rushton JL, Fant KE, Clark SJ.
Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder.
Pediatrics. 2004;114(1):e23-8. PubMed abstract
Salmeron PA.
Childhood and adolescent attention-deficit hyperactivity disorder: diagnosis, clinical practice guidelines, and social implications.
J Am Acad Nurse Pract. 2009;21(9):488-97. PubMed abstract / Full Text
Shaw M, Hodgkins P, Caci H, Young S, Kahle J, Woods AG, Arnold LE.
A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment.
BMC Med. 2012;10:99. PubMed abstract / Full Text
Smith AK, Mick E, Faraone SV.
Advances in genetic studies of attention-deficit/hyperactivity disorder.
Curr Psychiatry Rep. 2009;11(2):143-8. PubMed abstract
Tourette's Syndrome Study Group.
Treatment of ADHD in children with tics: a randomized controlled trial.
Neurology. 2002;58(4):527-36. PubMed abstract / Full Text
This study offers support for using methylphenidate and/or the combination of methylphenidate/clonidine in the treatment of ADHD with tic disorder.
Vaidya CJ, Stollstorff M.
Cognitive neuroscience of Attention Deficit Hyperactivity Disorder: current status and working hypotheses.
Dev Disabil Res Rev. 2008;14(4):261-7. PubMed abstract
Vetter VL, Elia J, Erickson C, Berger S, Blum N, Uzark K, Webb CL.
Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/hyperactivity disorder [corrected]: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing.
Circulation. 2008;117(18):2407-23. PubMed abstract / Full Text
Visser SN, Danielson ML, Bitsko RH, Holbrook JR, Kogan MD, Ghandour RM, Perou R, Blumberg SJ.
Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011.
J Am Acad Child Adolesc Psychiatry. 2014;53(1):34-46.e2. PubMed abstract
Warikoo N, Faraone SV.
Background, clinical features and treatment of attention deficit hyperactivity disorder in children.
Expert Opin Pharmacother. 2013. PubMed abstract / Full Text
Wilens TE, Adamson J, Monuteaux MC, Faraone SV, Schillinger M, Westerberg D, Biederman J.
Effect of prior stimulant treatment for attention-deficit/hyperactivity disorder on subsequent risk for cigarette smoking and alcohol and drug use disorders in adolescents.
Arch Pediatr Adolesc Med. 2008;162(10):916-21. PubMed abstract / Full Text
Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M,
Stein MT, Visser S.
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.
Pediatrics. 2011;128(5):1007-22. PubMed abstract / Full Text
Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M,
Stein MT, Visser S.
Implementing the Key Action Statements: An Algorithm and Explanation for Process of Care for Evaluation, Diagnosis, Treatment, and Monitoring of ADHD in Children and Adolescents.
Pediatrics. 2011;128(5).
Appendix to ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.
Zimmer M, Desch L.
Sensory integration therapies for children with developmental and behavioral disorders.
Pediatrics. 2012;129(6):1186-9. PubMed abstract / Full Text
Occupational therapy with the use of sensory-based therapies may be acceptable as one of the components of a comprehensive treatment plan for children with developmental and behavioral disorders. Pediatricians and other clinicians should discuss the limitations of these therapies with parents.


text:
Andrejs Skuja works at Killzone developers Guerilla Games, where he's currently a senior concept artist specialising in character design.
Which is why, aside from a surprisingly interesting glance at the dumpsters and fold-out chairs of the future, this gallery will almost entirely feature his amazing work helping design the characters and costumes of the Killzone universe.
What I love about this stuff is the incidental stuff, the things beyond the men with the guns. Like what pretty ladies look like in the Killzone universe. Even on Helghan, there is high fashion!
You can see more of Andrejs' work at his personal site.

subset: commoncrawl


text: Okay here is my question i can do very little programming. I can semi write a program in C++ that inputs 3 test scores and then prints teh avgerage of the two highests scores. But what i can't do is Input 3 values and output one of the following three messaes that best describes the three Values 1. THREE VALUES EQUAL 2. TWO VALUES EQUAL 3. NO VALUES EQUAL. so if someone could kinda of explain how to go about writting the code for a program like this please get back to me


text:
China Opens Longest High-Speed Railway
China has became home to what it says is the world's longest high-speed rail line, a 2,298 kilometer stretch of metal bisecting the country between the capital Beijing in the north and the southern boom city of Guangzhou.
The opening of the line on Wednesday was greeted with much fanfare in state media and even its own bit of aircraft carrier style . The project signals that China hasn't given up on its rail ambitions despite major setbacks. Last year's deadly train crash near the city of Wenzhou laid bare deep problems with China's high-speed rail surge. China's Ministry of Railways has also endured hits to its finances. But the new line will help China reach its goal of having 18,000 kilometers of high-speed railway by 2015.
The question for Chinese travelers is whether the route beats the hassle of flying.
Anyone who has taken both in China knows that the process of getting on a train is much easier than getting on a plane – provided, of course, that you already have a ticket and aren't traveling during the Lunar New Year . The food's nothing to write home about, unless you like writing home about instant noodles, but the cars tend to be clean and the ride smooth.
In the case of the Beijing-Guangzhou line, a passenger will also need an extra dollop of patience. The ride takes eight hours, a sharp reduction from the previous 20 on the still-operational old-fashioned track between Beijing and Guangzhou. But that's roughly enough time to fly between the two cities twice with some airport shopping in between. Unlike the traditional line, the new line doesn't appear to offer an overnight service yet, so it isn't much of an alternative for a passenger hoping to catch some Zs.
In a note last week Barclaysid it sees high-speed rail as competitive in terms of travel time, price and comfort. It said the lowest price tickets came to 865 yuan (about $139) for the rail line and 1,190 yuan for air travel, adding that it sees long-term pressure particularly on China's short-haul flight operators.
Chinese airlines agree that high-speed rail represents competition, but dispute the idea that competition is heavy. A representative for Air China said the previous inauguration of the Beijing-Shanghai high-speed rail line pressured air ticket prices, but she said short flight durations still lure customers.
Airlines are also looking for ways to work with rail. James Wang, company secretary at China Eastern Airlines, said the airline has begun introducing ways to integrate tickets and luggage transfer between its planes and the rail lines, so that a traveler could choose to take a train to Shanghai to meet a friend for lunch before zipping to the airport to fly to Beijing on one ticket and without visiting baggage claim.
Mr. Wang also hopes a wider train network will encourage more Chinese people to travel, which he said could benefit the industry long term. "Travelers have more choice, and more choice means more travelers," he said.
–Carlos Tejada. Follow him on Twitter @CRTejada
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text:
Información de juego
- Página web oficial
- UI IdiomaEnglish
- PlataformaPC
- editorAsiasoft Corporation
- Enlace de descargar
Media Social
Game Product
Buy CabalSEA Alz:
- CabalSEA Alz for server Neptune sold by SEA Gamer Mall are for CabalSEA run by AsiaSoft. CabalSEA is the South East Asia version of Cabal Online.
- Cabal SEA currently into Episode IX - Rising Force, brings a whole new experience to CabalSEA players.
CabalSEA Game Info:
- Cabal is a free-to-play, 3D massively-multiplayer online role-playing game, developed by South Korean company ESTsoft.
CabalSEA Game Story:
A long time ago, the CABAL cleansed the land with fury and destruction. Amidst the needless devastation, seven great masters of Force Power led the remaining survivors to reconstruction. Now, almost a thousand years later, the CABAL puppeteer the evil again, breeding a child to be king and once again cleanse the land. It is up to you to face the incadors of Nevareth and uncover the conspiracy behind it...


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Just the other day, I became the lucky recipient of a brand new MacBook Pro Retina as my new work laptop. Nice! I'm sure many of you know what I was thinking–Mercury Playback Engine support! The GPU is also supported for hardware acceleration when creating ray-traced 3D compositions in After Effects, as well. More on that a bit later.
Premiere Pro
Upon launching Premiere Pro CC (lightning fast, by the way!), I noticed that only OpenCL processing was available in Project Settings > Video Rendering and Playback > Renderer. With the NVIDIA 650M GPU, I expected to see CUDA processing available, as well, as this video card supports both OpenCL and CUDA processing. I did not.
Note: Having access to both CUDA and OpenCL processing in Premiere Pro is only available in Mac OS X. The NVIDIA 650M will only support CUDA in Windows.
This is not a Premiere Pro issue, it is because CUDA drivers are not natively installed in your shiny new MacBook Pro. You need to do that in order for CUDA processing to work with the Mercury Playback Engine. For these drivers, go to the NVIDIA site:
I found the most current driver, along with an archive of earlier drivers, here: http://www.nvidia.com/object/mac-driver-archive.html
Download the driver and install it. After installation, check Apple > System Preferences for the CUDA control panel. Click on the control panel to access the controls. You can update the CUDA driver here, if there is one available. All CUDA updates can be accessed from the control panel, so it's a good habit to check it periodically.
To enable CUDA processing for the Mercury Playback Engine, first restart Premiere Pro. Then, head to File > Project Settings (note: for CS6 users, Project Settings are in the Project menu) to see if you have installed it.
You should now have access to CUDA processing for the Mercury Playback Engine, as shown (left).
If you are still having trouble enabling CUDA, the MacBook Pro is not seeing your NVIDIA card. You have two video cards in a MacBook Pro Retina, the NVIDIA 650M and the Intel HD Graphics 4000 built in card. I feel it is important to force the MacBook Pro Retina to use the NVIDIA 650M at all times so that it does not switch to the Intel card unnecessarily.
To do this, choose the Apple menu > System Preferences > Energy Saver and disable the Automatic Graphics Switching checkbox. That will ensure you are using the NVIDIA card at all times.
After Effects
The NVIDIA 650M in the MacBook Pro Retina is supported to accelerate ray-traced 3D compositions in After Effects, however, this is not recommended. Unfortunately, the NVIDIA 650M has barely enough VRAM to support acceleration for ray-traced 3D compositions. See this forum post by Todd Kopriva for details: http://forums.adobe.com/thread/1326404?tstart=0
That said, users will probably try to enable acceleration in their MacBook Pro Retina anyway.
If you still want to enable CUDA processing despite potential problems you may run into, launch After Effects to make sure that the application is seeing your NVIDIA 650M. If you launch After Effects and get a Warning dialog box, the application is not seeing your GPU. The reason is that the video card may have too many other resources trying to use the VRAM (like other applications, web browsers, or connected hardware), therefore, After Effects will not enable the card because there is not enough VRAM available.
If this happens, click OK in the dialog box, and close After Effects. Close other applications, web browsers, and disconnect any hardware device reliant upon the GPU. Then, restart After Effects. Note if you get the Warning dialog box when inspecting Preferences.
If CUDA is still disabled, reboot the MacBook Pro Retina, and then relaunch the application. CUDA should now be enabled.
You can ensure that CUDA is enabled by checking the GPU Information dialog box.
To view the GPU information dialog box, choose Preferences > Preview, and then press the GPU Information button to launch the dialog box.
If CUDA information is available, then you will now have access to the benefits of CUDA.
For best performance, choose System Preferences > Energy Saver from the Apple menu. Click the Power Adapter button and disable Automatic Graphics Switching, and then close System Preferences.
If you continually are running out of VRAM when using hardware acceleration for ray-traced 3D rendering, it may be a better idea to do this on a computer with a NVIDIA card that has more VRAM.
Adobe Media Encoder
Adobe Media Encoder also utilizes GPU acceleration for encoding certain items. After launching the application, look in the Queue panel and inspect the menu at the bottom of the panel. There you should see some familiar choices for GPU acceleration. If CUDA processing is not available, try closing other applications and any web browsers which take up GPU resources. If that does not work, restart the MacBook Pro and CUDA processing should again be available.
I hope this article helps you troubleshoot problems you may be having enabling the NVIDIA 650M for CUDA processing in Adobe video applications.


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Calhoun County's 2017 Summer BreakSpot program, which offers free nutritious meals for children 18 and under was recently expanded to include a seventh site at the Altha Church of God. The Calhoun County School District also partners with the Calhoun County Public Library system during the months of June and July to provide this valuable service to the young people of Calhoun County. Superintendent Yoder stated, "The partnership with Calhoun County's Public Libraries, as well as faith-based organizations within our community, is a natural fit for the Summer BreakSpot program. Students gather at these locations to read and participate in summer activities."
The following sites are participating in the 2017 Summer BreakSpot program:
- Blountstown Elementary School
- Hugh Creek Public Library
- Kinard Public Library
- Shelton Public Library
- Mossy Pond Public Library
- Fresh Start Vision Ministries
- Altha Church of God
District 2 school board member Ray Howell stated, "Partnering with and expanding the summer food service program to include the Altha Church of God is an excellent way for the Calhoun County School District to serve the children within our community. I'm excited about this expansion of the Summer BreakSpot program."
"This program provides healthy meals to hundreds of thousands of Florida children throughout the summer," Commissioner of Agriculture Adam H. Putnam said. "Studies show kids who eat nutritious food perform better academically." Last summer, more than 4,200 sites statewide helped serve nearly 16 million meals to Florida children. The number of Summer BreakSpot meals served during the summer has increased by 46 percent since Commissioner Putnam and the Florida Department of Agriculture assumed responsibility of the program in 2012.
Summer BreakSpot is part of the national Summer Food Service Program, a federally funded program operated by the U.S. Department of Agriculture and administered in Florida by the Florida Department of Agriculture and Consumer Services. Eligible sponsors, including nonprofit organizations, schools, churches, camps, local governments and more, serve nutritious meals and snacks free to low-income children under the age of 18 during the summer months. For more information about the Florida Department of Agriculture and Consumer Services, visit FreshFromFlorida.com.


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Welcome to the SJSU Counseling and Psychological Services (CAPS) website!
Having a student in college can be an exciting time, and also a stressful time. With all the changes and development that students go through, it is natural for students to feel overwhelmed, anxious, or depressed at times. It can be difficult to support your student during these times. We at CAPS are here to help your student succeed, and encourage you to look at some of our parents resources or call us if you have any questions or concerns. We are a group of mental health professionals experienced and dedicated to working with college students, and look forward to partnering with you to help your student.
To read some tips on how to support your student and learn more about any of our services, please click on any of the links to the right on the side navigation menu.