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Attention-deficit/hyperactivity disorder (ADHD) is the most common mental disorder in childhood, and primary care clinicians provide a major component of the care for children with ADHD. However, because of limited available evidence, the American Academy of Pediatrics guidelines did not include adolescents and young adults. Contrary to previous beliefs, it has become clear that, in most cases, ADHD does not resolve once children enter puberty. This article reviews the current evidence about the diagnosis and treatment of adolescents and young adults with ADHD and describes how the information informs practice. It describes some of the unique characteristics observed among adolescents, as well as how the core symptoms change with maturity. The diagnostic process is discussed, as well as approaches to the care of adolescents to improve adherences. Both psychosocial and pharmacologic interventions are reviewed, and there is a discussion of these patients' transition into young adulthood. The article also indicates that research is needed to identify the unique adolescent characteristics of ADHD and effective psychosocial and pharmacologic treatments.
Attention-deficit/hyperactivity disorder (ADHD) is the most common mental disorder in childhood,1 and primary care clinicians provide a major component of the care for children with ADHD.2 To improve the care of those children, the American Academy of Pediatrics developed practice guidelines for the diagnosis and treatment of ADHD among children 6 to 12 years of age who are evaluated by primary care clinicians.2,3 However, because of limited available evidence, the guidelines did not include adolescents and young adults.
Contrary to early views of the disorder that indicated that it might represent a maturational lag and suggested that children would grow out of it,4 it has become clear that, in most cases, ADHD does not resolve once children enter puberty. For the majority of children diagnosed with ADHD, as many as 65%,5,6 the diagnosis persists into adolescence. When the diagnosis of ADHD is made during childhood, the task for clinicians is to continue treatment as long as needed. However, some adolescents present without having been diagnosed, and the symptoms of the disorder may be subtler during the teenage years. Therefore, it is important for clinicians who care for adolescents and young adults to be knowledgeable about diagnosing and treating ADHD. It is the intent of this article to review the current evidence about the diagnosis and treatment of adolescents and young adults with ADHD and to indicate how the information informs practice.
Clinical Manifestations in Adolescence
The most obvious adolescents to identify as needing treatment are those who were diagnosed with ADHD in childhood. Studies have shown repeatedly that the majority of those diagnosed with ADHD while in elementary school continue to have significant manifestations of ADHD throughout adolescence and continue to need treatment.5,6 Many studies have also shown that the most salient manifestations of ADHD change during adolescence. Hyperactivity, although still present, becomes much less visible during this age period.7 Academic problems that might have been less noticeable or were treated effectively during elementary school may become much more of a problem. In middle school and high school, cognitive demands increase significantly, and the adolescent is expected to become more independent of adult supervision.8 Students are exposed to multiple teachers and classes, and the amount of assigned homework increases. Finally, problems with peer relationships become more obvious as the social environment changes with adolescence and peer interactions assume a new importance.
These changes in context, expectations, and maturation result in very different case presentations than among school-aged children. In fact, the diagnosis of ADHD may be missed if an adolescent has the predominantly inattentive subtype.9 Although studies addressing differences between the subtypes with an adolescent population do not exist, it is our clinical impression that many of the differences reported for children persist in adolescence. For example, children with the inattentive subtype have been described by teachers as exhibiting less disruptive behavior but higher degrees of social impairment, unhappiness, and anxiety or depression, compared with children with the combined type.10 These problems may produce greater impairment in adolescence than in childhood because the demands for independence and the complexity of social functioning increase. Similarly, Milich et al11 summarized data indicating that the age of referral and recognition of the problem is older for children with the inattentive type, compared with the combined type. These children are more likely to be female than are children with the combined type, although male students still outnumber female subjects.11 The absence of disruptive behavior problems in this group disguises its identity, but these adolescents suffer significantly from problems such as disorganization, inability to follow through on academic tasks, and difficulty sustaining attention for extended academic projects.
Other Characteristics of Adolescents With ADHD
Adolescents with ADHD often seem emotionally immature, compared with their same-age peers.12 They often do best when interacting with younger children or in the environment of adults who tolerate their immature behaviors. Adolescents and children with ADHD often display affect, both negative and positive, that is excessive for the situation.13 The symptoms include becoming frustrated easily and having a "short fuse," with sudden outbursts of anger. In the extreme, the symptoms reflect co-occurring oppositional defiant disorder, as described below. Cognitive impairments become increasingly problematic during adolescence. These impairments may have widespread effects that often seem like behavioral problems and are not recognized as part of the ADHD. The adolescents procrastinate and, after having started, are distracted easily or have difficulty tracking and completing their projects, especially when the task requires a good deal of time and effort.14
Children with ADHD have been reported to have significant sleep disturbances, unrelated to medication status, that are characterized by dyssomnias, parasomnias, and sleep-related involuntary movements.15 Sleep disturbances among adolescents with ADHD have not been studied as thoroughly as has been the case with children and are complicated by the fact that adolescence is a developmental period that often includes sleep disturbances.16 Although stimulant medication does disrupt the sleep of adolescents with ADHD frequently,16 it is important for prescribing physicians to establish a baseline of sleep behavior before initiating stimulant treatment, to provide a valid comparison for the determination of medication-induced sleep disturbances.
Co-occurring Disorders
Between 25% and 75% of adolescents with ADHD also meet diagnostic criteria for oppositional defiant disorder or conduct disorder,17 which results in significant additional impairment that increases the difficulty of treating these adolescents. Others reported similar increased risk for conduct disorder and increased risk for adolescents with ADHD to meet diagnostic criteria for a substance use disorder or mood disorder.18 Long-term follow-up studies of children diagnosed with ADHD found that, in late adolescence and early adulthood, there is increased risk for antisocial personality disorder,19–22 substance use disorders, and depression.19 In a sample of 9- to 16-year-old subjects who met criteria for attention-deficit disorder (ADD) with or without hyperactivity,23 48% had comorbid depression/dysthymic disorder, 36% had comorbid oppositional defiant disorder/conduct disorder, and 36% had comorbid anxiety disorder. These incidence rates are comparable to the Multimodal Treatment Study of ADHD data for younger children regarding the comorbidity of anxiety and oppositional defiant disorder with ADHD but reflect a 12-fold increase in the reported incidence of depressive/dysthymic symptoms, with an incidence that is much closer to that found for depressive comorbidity in samples of adults with ADHD.24 The high rate of comorbidity makes working with these comorbid disorders an inevitable part of treating adolescents with ADHD, leading to a need for assessment and treatment that target a range of impairments.
Cognitive Deficits
In addition, children and adolescents with mild to moderate degrees of mental retardation, for example, may have behavioral symptoms consistent with a diagnosis of ADHD and may also respond to medication and other ADHD treatments.25 Although the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,9 excludes individuals with pervasive developmental disorders from having a co-occurring diagnosis of ADHD, children and adolescents with these disorders may also have symptoms of ADHD and may benefit from treatment for this condition as well as treatment for their pervasive developmental disorders.
Oppositional Defiant Disorder
The most noticeable psychiatric disorder that often occurs with ADHD in adolescence is oppositional defiant disorder. Adolescents with oppositional defiant disorder are chronically much more argumentative, negativistic, and defiant than most other adolescents, even most others with ADHD.26 Although most adolescents with ADHD and oppositional defiant disorder do not manifest the more severe behavioral problems of conduct disorder, a serious pattern of delinquent behavior, those with oppositional defiant disorder often suffer significant problems in school, family, and social relationships. A central factor underlying this disorder is impairment in the adolescent's ability to modulate and to cope with the routine frustrations of daily life.
Anxiety Disorders
Children with anxiety disorders may be tense and chronically anxious, quick to panic and often asking for reassurance, or they may tend to be socially phobic, extremely shy, and avoidant of unstructured interactions with any unfamiliar persons.9 Others with ADHD may have obsessive-compulsive disorder, characterized by persistent obsessional fears that remain unspoken or tightly constrained by compulsive behaviors of checking, repeating, counting, cleaning, arranging, or hoarding that may be carried on only in private.9 Adolescents with comorbid ADHD and anxiety may present a complicated clinical picture, because these disorders are characterized by thinking too little (ADHD) and thinking too much (anxiety). Careful assessment is important when attempting to diagnose these comorbid conditions.
Mood Disorders
ADHD is also associated with an elevated risk of dysthymia, sometimes in combination with anxiety disorders or oppositional defiant disorder.27 These disorders may be manifested by persistent profound unhappiness, with weeks and months of being unable to find any real pleasure, even in activities that once were enjoyable. The unhappiness may manifest as a persistently irritable mood. Dysthymic symptoms often are alleviated among adolescents who receive effective treatment for their ADHD but, in cases in which such symptoms persist despite effective ADHD interventions, specific counseling and medication treatment for depressive symptoms may be indicated.28 Symptoms such as hypersomnia or hyposomnia, extremes of excessive or insufficient appetite, marked loss of energy, intense feelings of worthlessness, and persistent feelings of "not caring any more" may indicate the presence of comorbid major depressive disorder.9 This is a potentially life-threatening comorbid condition, because the combination of depression and a disruptive behavior disorder has been identified as a particularly high-risk condition for a suicide attempt.29 As a result, screening for depression among patients diagnosed as having ADHD is highly recommended. When signs of this morbid syndrome appear, careful assessment of depressive severity and the risk of self-injurious or life-threatening behaviors is needed, and conventional ADHD treatments alone are not likely to be sufficient.
There is a great deal of debate about the overlap of bipolar disorder and ADHD30 and, until an accepted definition and diagnostic criteria appropriate for children and adolescents are developed, this debate will probably continue. Generally, bipolar disorder can be distinguished from severe ADHD by the presence of elated mood, grandiosity, flight of ideas or racing thoughts, and a decreased need for sleep.31 Whenever possible, adolescents with complicated psychiatric presentations related to both ADHD and bipolar disorder should be referred to specialists in the area.
Substance Use and Abuse
Children with ADHD are at increased risk for developing substance abuse as they grow older. Studies of adults with substance use disorders9 show an overrepresentation of those with ADHD, with several reports indicating that between 15% and 25% of adults with substance use disorders have ADHD.32,33 The presence of ADHD is also associated with greater severity of substance use disorders, including higher rates of substance-related motor vehicle accidents and treatment episodes.33–35 One study found that the risk of developing substance use disorders over the lifespan for individuals with ADHD was twice that of individuals without ADHD.36
Prospective studies of children with ADHD found increased drinking and risk of substance use disorders during adolescence, which might be compounded by co-occurring conduct disorder or bipolar disorder.34,37–39 In addition, individuals with ADHD start smoking at a younger age40 and have higher rates of smoking than do individuals without ADHD.41 Although adolescents with ADHD are at greater risk of substance use, the evidence suggests that appropriate treatment of ADHD, including the use of psychostimulant medication, does not increase that risk. A recent meta-analysis by Wilens,42 which identified a total of 7 studies on this topic, found that stimulant pharmacotherapy was protective with respect to substance use disorders later in life (odds ratio: 1.9) and the effect was stronger among adolescents, compared with adults.
When the question of ADHD first arises during the adolescent years among individuals without previous diagnoses, the presence of substance use confounds the diagnostic process. Recurrent use of alcohol or drugs, including cannabis, may cause inattentiveness and other cognitive impairments.43–46 Clinicians should therefore be cautious in making an ADHD diagnosis during adolescence when substance use is present and childhood symptoms are absent. It may be best to reassess an adolescent suspected of having ADHD after at least a 1-month period of abstinence from all psychoactive drugs.
Assessment of ADHD among adolescents is often more challenging than assessment among younger children. Students in preschool and early elementary grades are usually supervised closely by parents and, for most of the school day, by 1 teacher, who is able to observe much of the child's academic performance and social interaction. Observations by parents and the primary classroom teacher are usually a rich source of information to guide assessment for possible ADHD among younger children.
In contrast, adolescents usually have 5 to 7 different teachers, each of whom are responsible for 100 to 150 students and see each student for just a small portion of each school day. Outside school, adolescents are often involved in many activities where parents have very little direct contact to observe details of their strengths and problems. Parents can usually provide helpful information about homework patterns, school grades, and daily routines of their adolescent son or daughter but little direct information on school function, social interactions, and peer relationships.
A study by Mitsis et al47 reported that parent-teacher agreement regarding the diagnosis of ADHD was only moderate (74%). Teachers tended to report a greater number of school symptoms than did parents, and parent reports of school behaviors were found to be influenced by their observations of behaviors in the home. The authors concluded that parent reports of ADHD behaviors in school settings are not an adequate substitute for direct teacher input. The subjects in that study were in elementary school, and parents frequently profess to know more about their child's behavior at the elementary school level than at the middle or high school level, which suggests that parent reports of school behaviors may be more inadequate in secondary schools than they were found to be in elementary school. Adolescents' needs for independence and privacy make it even more difficult for parents to obtain information about how their son or daughter is really doing in school, extracurricular activities, and social relationships.
Although obtaining assessment information from secondary school teachers may be important, there are many obstacles. First, teacher ratings do not provide information on symptoms and functioning manifested in less-structured settings such as the cafeteria, hallway, and bus. Second, inter-rater reliability is poor with secondary school teachers.48 Agreement is best for questions pertaining to hyperactivity and academic progress and improves over the academic year from fall to spring semesters.49 Given these problems, clinicians are encouraged to collect information from multiple teachers and from other sources such as counselors. If the adolescent has an individual education plan or 504 plan,50 then it may be possible to receive help from the school in organizing the assessment effort.
Given the limitations of teacher and parent reports, it would be ideal if adolescents could provide reliable self-reports about symptoms and impairment; however, this does not seem to be the case. Consistent with studies reporting information for younger children, adolescents with ADHD tend to under-report dramatically their level of impairment and symptoms.51–53 Interviewing adolescents and using self-report scales such as the Brown ADD Scales for Adolescents54 or the Conners-Wells Adolescent Self-Report Scale55 remain important components of the clinical evaluation. However, the information should be interpreted with the understanding that frequently it is an under-representation of impairment.
The presenting problems of adolescents continue to include many of the same behaviors as exhibited by children with ADHD. Their context, complexity, and potential for serious harm, however, change considerably. As a result, assessment and treatment must address not only the core symptoms of the disorder but also associated sequelae, including academic problems, impaired peer relationships, delinquent behavior, dangerous driving, substance use, impulsive sexual activity, and defiance.8,56
ADHD evaluation of an adolescent should include a review of recent report cards and school progress reports, especially noting patterns in teacher comments, and a review of psychoeducational testing results, if testing has already been completed. Reviewing previous school reports may be helpful in documenting problems before the age of 7 years. Psychoeducational testing cannot establish an ADHD diagnosis, but it may offer useful information. Results can indicate the range of an adolescent's cognitive abilities and can identify specific areas of strengths and weaknesses. Extensive batteries of neuropsychologic tests are usually not indicated for assessment of ADHD, unless there are questions about other neurologic impairments.
Adolescents with ADHD may be eligible for special education services under the category of "Other Health Impaired."50 They are also at elevated risk for specific learning disorders involving reading, math, and/or written expression.57 It can be helpful for clinicians to encourage parents to request, in writing, that the school complete a multidisciplinary evaluation if there are problems with their child at school. The process can be aided by a report from the clinician documenting the diagnosis of ADHD. If school personnel initiate the evaluation process, then they are likely to include an individually administered achievement test such as the Wechsler Individual Achievement Test-Second Edition or Woodcock-Johnson Achievement Tests-Third Edition, to be compared with the student's grades and ability, as measured with an individually administered IQ test, to determine the presence or absence of impairment. Definitions of impairment vary according to the state and school district, but some comparison of these scores is used frequently to determine impairment.
Adequate assessment for ADHD among adolescents requires screening for other psychiatric disorders. As noted above, individuals with ADHD have two- to fivefold greater risk of developing ≥1 additional psychiatric disorder at some point in their lives, and many have multiple disorders, with onsets at various points in the life cycle. Broad-based rating scales such as the Child Behavior Check List58 or the Behavior Assessment System for Children59 are standardized scales to screen for possible co-occurring disorders. The Brown ADD Diagnostic Form for Adolescents-Revised54 and an interview outline in a book by Robin60 provide probe questions that can be used to inquire about indicators of possible co-occurring disorders.
Evaluating clinicians should also ask the parents and, privately, the adolescent about risk-taking behaviors. These behaviors include the use of tobacco, marijuana, alcohol, and other drugs and association with others who tend to engage in illegal or dangerous behaviors. For those old enough to drive a motor vehicle, clinicians should inquire about attitudes and behaviors when driving (eg, speeding). Adolescents with ADHD are at increased risk of having car accidents associated with injuries.61 To obtain adequate information about driving habits, pediatricians usually need to reassure adolescents that confidential disclosures will not be passed back to the parents.
Treatment Model
The National Initiative for Children's Healthcare Quality, adapting a "chronic care model"62,63 from the work of others, proposed that children with ADHD, including teens and adolescents, and their families require ≥6 supports in addition to an individualized and appropriate clinically based program.62,63 These supports are (1) community resources and policies (such as schools), (2) health care systems and organizations (such as health insurance), (3) clinical information systems (such as public health community-based monitoring), (4) decision support, ie, application of evidence-based guidelines such as the American Academy of Pediatrics ADHD assessment and treatment guidelines, (5) delivery system design, ie, planned interventions by a coordinated, multidisciplinary, professional team, and (6) family and self-management support; families and individuals are those who must implement treatment interventions, and such individuals must be educated adequately about these treatments. The following review refers to these supports and is consistent with treatment characterized as a chronic care model.
Education and Adherence
All individuals with ADHD need a basic understanding of the disorder, including the fact that this is a neurobiological disorder. It may be helpful to "destigmatize" ADHD by comparing it with a less-stigmatizing condition such as poor eyesight or asthma. With these conditions, individuals are not deemed to be at fault for having the disorder, because they were born with it. However, individuals can be limited in life by the disorder unless it is treated. People who have these disorders need to be reminded frequently that they are not "bad," "damaged," "stupid," or "mentally deranged," just people who need help in certain areas. Having ADHD is no different. It is also critical to inform adolescents that having ADHD is not a reflection of their intelligence.
Adolescents with ADHD may have negative attitudes toward medication use and may be nonadherent with pharmacotherapies. In their longitudinal follow-up study of 358 clinic-referred children with ADHD, Pelham, Molina, and co-workers64 reported that psychoactive medication usage decreased precipitously throughout adolescence, which indicates that stimulants or other psychoactive medications become an increasingly unpopular method of treatment as children mature beyond the elementary school period. In their sample, among the 87% of children who were medicated at some time in their lives, 27.9% had stopped taking medication by the age of 11 years and 67.9% had stopped by the age of 15 years. Starting medication in this age range was uncommon. Only 0.7% to 4.7% of the sample began taking medication between the ages of 11 and 15 years. Most individuals (86.5%) had started taking medication by the age of 10 years. Finally, one half of the participants in that study were in the adolescent age range at the time of their interviews (1998–2000), which suggests that recently improved, long-acting, stimulant preparations were available and might not ameliorate adolescent discontent with medication treatment for ADHD. In a separate, 3-year, longitudinal study,65 it was reported that 48% of the children between the ages of 9 and 15 years had discontinued medication. Age was a significant moderator of adherence, such that older children were less likely to be continuing with their medication.
The lack of treatment adherence is not always obvious to prescribing physicians, because it may be manifested by the absence of visits. Unless the physician is monitoring the patient in such a way as to note omissions and to follow up actively when they occur, the discontinuation of therapies may go unnoticed. When children reach adolescence, they are better able to defy parent requests; this is accompanied frequently by a belief that they do not have a problem and therefore do not need treatment.
Physicians and parents can often be frustrated by a lack of adherence to prescribed regimens when they have a strong belief in the value of behavioral and medical interventions for ADHD but have little control over whether the adolescent will actually take the medications or follow behavioral contracts.66 Important factors promoting adherence include self-concept,67,68 family stability,69–72, internal locus of control,68,70,73 increased motivation,74,75 simplified medication regimens,76 lack of adverse effects,70,77–79 and characteristics of the doctor-patient relationship, such as the physician's verbal and nonverbal communication skills and satisfaction of both the patient and the physician.80 The use of motivational interviewing techniques by physicians can help adolescents feel in control and make their own decisions about the use of medications and behavioral interventions81–85 (although the techniques have not been evaluated among adolescents with ADHD). This use can help diminish resistance and activate the motivation of the adolescents, 2 critical factors in successful treatment.86 If an adolescent prefers to forego medication at a given time, it may be helpful to concur and then to develop a plan with the adolescent that helps him or her achieve goals through the use of tutors, behavioral interventions, organizational help, or whatever he or she thinks will help. A reevaluation of this plan in 2 to 4 weeks can identify whether it is working and what needs to be changed. If the adolescent chooses to start medication at a later time, it is at his or her request and the physician may then be seen as an ally, rather than as an enforcer and an authority figure.
The pharmacologic management of ADHD relies on agents that affect dopaminergic and noradrenergic neurotransmission, namely, the stimulants, antidepressants, and antihypertensives.87–88 A new agent, a noradrenergic reuptake inhibitor, has also become available.
The most commonly used stimulants are methylphenidate (Ritalin, Ritalin LA, Ritalin SR, Concerta, Focalin, Methylin, Methylin ER, Metadate ER, and Metadate CD) and amphetamine compounds (Adderall, Adderall XR, Dexedrine, Dexedrine Spansule, and DextroStat). Stimulants have been shown to be effective for ∼70% of adolescents and seem to operate in a dose-dependent manner in improving cognition and behavior.89,90 The beneficial effects of stimulants are of similar quality and magnitude for adolescents of both genders and for younger and older children.91 Immediate-release preparations of methylphenidate and amphetamine are available in generic form. The extended-release formulations provide longer durations of action, resulting in the need for fewer daily administrations, elimination of school administrations, and thus fewer adherence issues and less potential for diversion and abuse. The extended-release preparations of the stimulants have durations of action that start ∼30 minutes after dosing and last 8 hours (Ritalin LA and Metadate CD) to 12 hours (Concerta and Adderall XR). Dosing starts at the lowest dose available. Doses exceeding those approved by the Food and Drug Administration have been used clinically. A recent multisite study of OROS methylphenidate with adolescents demonstrated that one third of the participants experienced the best efficacy with 72 mg daily, with good tolerability.92
There seems to be a dose-response relationship for both behavioral and cognitive effects of the stimulants among youths with ADHD,89,93 as well as for the most commonly reported short-term adverse effects, such as appetite suppression, sleep disturbances, and abdominal pain.89,94,95 Long-term adverse effects remain controversial, with mixed literature findings indicating only a weak association with motor tic development and variable results regarding height/weight decrement among prepubertal youths with ADHD.88,94,96
Survey studies suggest that diversion of stimulants, especially immediate-release preparations, continues to be noteworthy.97–99 Medications may be abused orally or by grinding them into powder and then administering them through nasal insufflation. Psychostimulant medications may also be diverted to peers, either as a "favor" to friends or for financial profit. For example, in a survey of junior and senior high students who were prescribed stimulants,100 7% had sold (diverted) their medications. Similarly, diversion of stimulants to young adults presumably without ADHD seems problematic.101 Survey studies with college students indicated that ∼11% of students without ADHD reported using methylphenidate or amphetamine recreationally (including intranasally).102 Recently Wilens97 presented data indicating that 11% of older adolescents and college-aged students were diverting their stimulants. Interestingly, diversion was exclusively with immediate-release but not extended-release stimulants and was confined largely to those with concurrent substance abuse or conduct disorder. More disturbingly, Low and Gendaszek98 reported that, in a survey study of 150 undergraduate students (ADHD status not assessed) at Bates College, 4% had misused amphetamine compounds, 7% methylphenidate, and 24% both (total of 36%). As a comparison with another abused substance, one third of subjects in that sample also admitted using cocaine. However, as noted above, recently published evidence indicates that pharmacotherapy of ADHD does not increase the risk for substance abuse among individuals with ADHD but seems to reduce the risk for substance abuse by one half.99
Atomoxetine (Strattera) is a recently approved, nonstimulant agent that has been approved for adolescents with ADHD. Atomoxetine is a highly specific, noradrenergic reuptake inhibitor with efficacy for ADHD.100,101 Moreover, atomoxetine seems to have efficacy for ADHD plus co-occurring disorders such as anxiety, tics, and depression. Atomoxetine has been shown to have similar efficacy and tolerability (side-effect profile) among adolescents, relative to more prototypic school-aged children with ADHD. In addition, long-term data indicate continued effectiveness with normal growth in height and weight and no unexpected adverse events occurring over 2 years.101
Atomoxetine demonstrates no abuse liability and is unscheduled by the Drug Enforcement Administration. Atomoxetine can be dosed once or twice daily; it should be initiated at a dose no higher than 0.5 mg/kg per day and increased to 1.2 mg/kg per day in 2 weeks. The peak efficacy of the medication seems to develop over 2 to 6 weeks. If adolescents continue to manifest symptoms, then the dose of atomoxetine can be increased to 1.4 mg/kg per day (100 mg per day) (Food and Drug Administration-approved dosing) to 1.8 mg/kg per day (maximal dose evaluated in clinical studies).100,101 The effects of atomoxetine are more gradual than those experienced primarily with stimulant medications.
Adverse effects of atomoxetine among adolescents (as among younger children) include sedation (usually noted during initial titration), appetite suppression, nausea, vomiting, and headaches. Most short-term adverse effects can be managed by changing the time of administration of the medication. Most recently, rare occurrences of hepatotoxicity that resolves when the medication is stopped have been reported (Lilly, personal communication). Data on the long-term adverse effects of atomoxetine are limited. There do not seem to be drug interactions with the stimulants, a combination that might be very helpful in refractory cases of ADHD. Case reports of this combination have been published,102 but there have been no formal studies of the effects of combined therapy. Atomoxetine doses should be reduced if the drug is administered with agents that inhibit the cytochrome P450 microsomal enzyme system, such as paroxetine (Paxil). Until additional evidence defines its safety and efficacy, the drug should be considered for adolescents with conditions unresponsive to stimulants, those with a preference for a nonstimulant, and those for whom there is concern about abuse by the patient or family members.
The antidepressants are off-label and are considered second-line medications for ADHD. The tricyclic antidepressants, eg, imipramine (Tofranil), desipramine (Norpramine), and nortriptyline (Pamelor), block the reuptake of neurotransmitters including norepinephrine. Tricyclic antidepressants are effective in controlling behavioral problems and improving cognitive impairments associated with ADHD but are less effective than the majority of stimulants, particularly for cognitive impairments.88 Desipramine and nortriptyline were shown in published reports to have both short-term and long-term effects among adolescents.103,104 The tricyclic antidepressants should be considered only when adequate trials with both stimulant medications (amphetamine compounds and methylphenidate) have failed, atomoxetine is ineffective, and behavioral interventions have been tried. Dosing of the tricyclic antidepressants starts with 25 mg daily and is titrated upward slowly to a maximum of 5 mg/kg per day (2 mg/kg per day for nortriptyline).104 Common adverse effects among adolescents include sedation, weight gain, dry mouth, constipation, and headache. Four deaths among children with ADHD (including 1 adolescent) who were treated with desipramine were reported.105 However, independent evaluation of those cases failed to support a causal link.106 Because minor increases in heart rate and the electrocardiographic intervals are predictable with tricyclic antidepressants, electrocardiographic monitoring at baseline and at the therapeutic dose is suggested (although not mandatory).107
The novel dopaminergic antidepressant bupropion (Welbutrin) has been reported to be effective and well tolerated in the treatment of ADHD,108 although it remains untested among adolescents with ADHD under controlled conditions and therefore is a second-line treatment. One open-label study among depressed adolescents showed improvement in both ADHD and depression.109 Bupropion should be started at 100 mg and slowly titrated upward, with beneficial effects for ADHD being noted generally at 300 to 400 mg daily.
The antihypertensive agent clonidine (Catapres) has been used increasingly as a second-line medication for the treatment of ADHD, particularly among adolescents with hyperactivity and aggressiveness.110 Although the effect of clonidine on ADHD is not as robust as that of stimulants, a meta-analysis suggested a moderate effect size (0.58) for this agent on symptoms of ADHD co-occurring with tics, aggression, or conduct disorder.110 Clonidine is a short-acting agent, with daily doses ranging from 0.05 mg to 0.6 mg, given in divided doses up to 4 times daily. Clonidine is commonly used clinically in addition to stimulants and antidepressants. Short-term adverse effects include sedation (which tends to subside with continued treatment), dry mouth, depression, confusion, electrocardiographic changes, and hypertension with abrupt withdrawal. A recent multisite study demonstrated the usefulness of clonidine alone and in combination for the treatment of ADHD among children with tics.111 Abrupt withdrawal of clonidine has been associated with rebound; therefore, slow tapering is advised. Guanfacine (Tenex) has also been used to treat ADHD, alone or in combination with tic disorders, among preadolescent children.112 Dosing of guanfacine generally starts at 0.5 mg per day and is increased as necessary to a maximum of 4 mg per day, in 2 or 3 divided doses.
Although the serotonin reuptake inhibitors (for example, Prozac) are not useful for treatment of ADHD, venlafaxine (Effexor), because of its noradrenergic reuptake inhibition, may have mild efficacy for ADHD.113 Monoamine oxidase inhibitors (Nardil and Parnate) have been shown to be effective among adolescents with ADHD.114 However, the potential for hypertensive crises associated with tyramine-containing foods (such as most cheeses) and interactions with prescribed, illicit, and over-the-counter drugs (pressor amines, most cold medicines, and amphetamines) limit its usefulness. Provigil and cholinergic agents remain untested among adolescents.
Psychosocial Interventions
Types of Treatments
Psychosocial treatments encompass a broad set of interventions, including behavior therapy, academic interventions, family therapy, and care coordination. Relatively little research has been conducted on psychosocial treatments for adolescents with ADHD,53 compared with the vast amount of treatment outcome research completed for children with the disorder.115 Nevertheless, there are important practice implications for adolescents that can be surmised from this work.
School Problems
Problems at school tend to be the most common complaints of parents of adolescents with ADHD.116 These usually include poor performance on tests and quizzes, missing assignments, careless work, and poor writing. Psychosocial interventions targeting these areas include behavioral techniques addressing organization and academic interventions, including training in note-taking and study skills, that focus on underachievement.60,117,118 These interventions tend to be labor intensive and are provided frequently by teachers and other school personnel. School districts' willingness to provide these interventions to adolescents varies. Some schools prioritize these services and provide them when the problems are recognized. Receiving these services in other districts can be enhanced by having a child identified as eligible to receive services under Section 504 of the Rehabilitation Act or in the "Other Health Impaired" category of the Individuals with Disabilities Education Act.50 Although a diagnosis of ADHD does not by itself qualify a student for these services, an adolescent with ADHD is likely to be found eligible if the ADHD is accompanied by significant academic impairment. Physicians may facilitate this process by educating parents about these services (www.ideapractices.org/index) and providing documentation of the diagnosis and impairment.
Substance Use
Because substance abuse becomes a prominent issue among adolescents, educating parents and patients about the risks and informing them about appropriate local prevention and intervention resources may be very helpful. The data suggest that this should be performed at a relatively young age (<11 years), because youths with ADHD begin their experimentation earlier than do children without the disorder.35,119 Some parents may request that their physician conduct random drug screens. Although parents may want to know the truth about their child's experimentation and use of illegal drugs, conducting these screens against the wishes of the adolescent can affect family relationships seriously. For example, parents who request a drug screen communicate to their child that they no longer trust him or her. Although this may be obviously true in some families, in others this message may disrupt family functioning seriously. Furthermore, it can lead to power struggles and defiance by adolescents who refuse to comply with these screens. Adolescents also may find ways to defeat the validity of the screens, by drinking excessive amounts of water or using products that are readily available via the Internet. Depending on the age of the adolescent and the consent laws in the state, the child's consent may be needed to conduct the screens, and the American Academy of Pediatrics recommends that drug screening not be performed without a child's knowledge and consent except in cases of medical necessity.120 In addition, parents need to know what to do if the test results are positive. Parents wonder frequently how to respond to this news, and counterproductive responses are not uncommon. Pediatricians conducting drug screens should consult with a toxicologist or addiction professional at the time the test is ordered, to avoid false-positive and false-negative tests.
Family Stress
In addition to concerns about substance use, the cumulative effect of the chronic stress of raising a child with moderate to severe ADHD can take a serious toll on parents.121 Parents respond to this stress in many different ways, and some of these reactions may affect the adolescent, the parents, and the siblings negatively. Simple recognition and assessment of parents' stress and coping can be a useful psychosocial intervention for many parents. Parents may need supportive services, and physician encouragement and appropriate referrals can facilitate this need being met. Although early reports indicate that parent training and family therapy are not as effective for adolescents with ADHD and their families as they have been for children with ADHD,122 these interventions can be helpful for some parents and should be considered for families exhibiting significant distress. Furthermore, some forms of family therapy that have not been assessed directly with families of adolescents with ADHD have been found to be effective with families of adolescents with problems such as substance abuse and should be evaluated with this population.123
Social Impairment
The social impairment reported frequently to accompany ADHD among children continues into adolescence.124 The consequences of these problems may be even greater for adolescents than for children, because the cruelty of peer rejection and bullying can be greatest in the young adolescent years. In addition, social impairment with ADHD increases the risk for substance use and other problems.125 Effective psychosocial treatments for adolescents with social impairment have not been reported, although modest results were observed in initial studies of comprehensive and intensive psychosocial treatment programs.117 These interventions incorporated novel techniques, including videotape reviews of naturally occurring social behavior, and emphasized strategies to facilitate generalization. Many traditional social skills interventions fail to generalize to natural settings and have minimal impact on social functioning126,127 or have not been evaluated with adolescents.128
The data describing automobile accidents and traffic violations involving adolescents with ADHD are likely to lead many parents of these young drivers to ask their physicians for guidance.61 Unfortunately, there are no reports of effective psychosocial interventions for this problem and only preliminary information on the potential benefits of medication.129 Parent management strategies related to the use of an automobile have implications for this difficult area. Parents may restrict the peers who can ride with their adolescent driver, limit the time of day the car can be used, and provide close monitoring. The risks associated with driving problems are increased significantly if the adolescent is experimenting with drugs or alcohol.129 Parents should be encouraged to discuss this topic regularly with their teenager and to follow up aggressively on any suspicions. In some situations, maintaining driving privileges may be contingent on demonstrating responsible behavior in other settings, such as home and school, and possibly participating in laboratory testing for drugs. For some adolescents with ADHD, it may be important to plan medication dosing so that the adolescents have coverage during periods in which they are likely to be driving.
Primary care physicians are being incorporated increasingly into important roles in the delivery of universal and selective psychosocial mental health services.130,131 Implementing these basic psychosocial interventions in a busy pediatric practice is likely to be a challenge. Because of the wide range of impairment among adolescents with ADHD, care is often provided by a variety of professionals. As other providers become involved, the coordination of care becomes a central issue and can be facilitated by the sharing of information about the services and measures of progress. This system is part of the medical home concept.132 Collaborating with a qualified psychologist or mental health counselor with expertise working with adolescents and behavioral techniques can be a practical solution; however, there are many communities without providers with expertise in these areas. Counselors and teachers at secondary schools may provide many of these services and may be very interested in collaborating with a physician practice.
Insurance Coverage
The peer-reviewed medical literature about the transition from secondary education for young people with ADHD is sparse. It is clear, however, that the move to increasing independence and postsecondary training is fraught with difficulties for all adolescents with chronic medical conditions.133 Before they can begin to consider training and other issues, they would benefit from finding ways to continue medical care and maintain at least the semblance of a medical home.
Even in childhood, health insurance for individuals with ADHD is limited. A survey of Children and Adults with Attention-Deficit/Hyperactivity Disorder members134 found that 82% of health insurance policies held by a sample of members contained assessment of ADHD limitations and 24% of health policies did not cover the treatment of ADHD; of the 76% of policies that covered the treatment of ADHD, 83% contained treatment limits. In addition, the out-of-pocket obligations were higher than for other health conditions and were similar to those for other psychiatric conditions.
The insurance coverage issues are magnified when a child becomes an adult. At a time when many of the family structures that have supported them through their school careers begin to change and become more tenuous, adolescents' ability to obtain and fund medical care decreases precipitously. Young adults, 18 to 24 years of age, are more likely than any other age group to be uninsured.135 Of Americans between the ages of 18 and 24 years, 31.6% are without medical insurance, compared with 12.0% for those ≤18 years of age.136 Many commercial policies no longer cover young people under their parents' policies, particularly if the young people are not enrolled full-time in college or other advanced training.136 Because the median costs of health care for individuals with ADHD are twice those for individuals without ADHD,137 obtaining private health insurance on their own before they are employed full-time is likely to be difficult for individuals with ADHD. Government health care programs also cease after age 18 for unmarried people without children.138 The ability to pay for continuing medical care and medication therefore becomes a critical issue for young adults with ADHD, which is complicated by preexisting-condition exclusions present in many policies.
Access to Care
After reaching the age of majority, fewer young people are cared for by pediatricians, and family and adult physicians may be less comfortable dealing with young people with ADHD. Although some patients continue care for ADHD through the services of the psychiatric community, the inability of these physicians to provide comprehensive medical services would preclude their replacing a medical home model for their patients,139,140 which would be provided ideally by the patient's pediatrician. College health services may provide support for individuals who are enrolled in college, but such services cannot be expected to offer comprehensive care when the student is home or outside the school calendar. Whenever possible, it is important to have a plan on how to transition these individuals into the adult health care system.
Anticipatory Guidance
The need for pediatricians and other health professionals to provide anticipatory guidance to their graduating patients with ADHD is important. Adolescents with ADHD who are leaving home for what may be the first time are particularly vulnerable to the consequences of sudden diminution of parental supervision. In preparing students with ADHD for being away at school, physicians need to caution them about the increased risk of their becoming smokers141 and their increased risk of driving-related morbidities.56 In addition to a general warning to college-bound students to avoid binge drinking, students with ADHD need to know that they have an increased long-term risk of alcohol and illicit drug use if they are not receiving appropriate treatment.142 Individuals preparing for college need to become aware of how to navigate the complexities of dealing with college scheduling and course planning, acquiring study skills, and learning to access any special services for students with ADHD that their college may offer. They also need to deal with the more basic problems of following a schedule on their own and taking their medication reliably. There are several educational materials that may be useful for them to read.143–145 They should be reminded of the potential for theft in keeping a controlled substance in their dormitory rooms and the hazards of sharing or selling controlled substances to their peers.146
Testing Accommodations
Both the SAT147 and ACT148 have processes in place to allow students with ADHD to apply for special accommodations, including extended testing time. However, there are strict requirements for the type and timing of documentation required. Details are available at the Educational Testing Service Web site (www.ets.org/disability/adhdplcy.html). Both testing services have subscribed to the basic tenets established by the Consortium on ADHD Documentation149 and have ceased flagging tests taken with special accommodations.150 For consideration for military service, each enlistee must take and pass the Armed Services Vocational Aptitude Battery, a timed test for which no accommodations are permitted.143
Military Enlistment
Enlistment in the military is uncertain for those with ADHD. The reasons for rejection for appointment, enlistment, or induction include a history of immaturity and impulsiveness, a chronic history of academic skill deficits that interfere with work or school after age 12, and the current use of medication to improve or to maintain academic skills. Under certain circumstances, individual military services may grant waivers to individuals who do not meet the basic eligibility criteria. Demonstrating success in either school or work for a certain period of time without the use of medication is basic in whether a waiver will be granted.143
Planning for the future is complicated for all graduating high school students but offers special challenges for those with ADHD. Educational attainment is less for patients with ADHD, and their future occupational outcomes are of lower ranking than those of their cohorts.151 Young people who have ADHD, predominantly inattentive type, or ADHD, combined type, have fewer years of school and are less likely to graduate from college, compared with young people without ADHD. Furthermore, youths with the combined type of ADHD have higher rates of oppositional defiant disorder, suicide attempts, and arrests than do those with the inattentive type.152
High school, college, and other counselors have made themselves available to help such students, and vocational tests are available to help assess likely job satisfaction, but the usefulness of such assistance for this population is not well documented in the medical literature. Anecdotally, special services programs provided by colleges seem to fulfill real needs for students with ADHD, including providing late course-dropping dates, special registration assistance, adaptive equipment such as computers, and note-takers for qualifying students.153 Some communities offer support for students with ADHD through state vocational rehabilitation services or through ADHD coaching services.154 Although there is little research in this area, there are a number of organizations, publications, and websites offering information, encouragement, and support to adolescents making the transition from secondary school to work or postsecondary education.155–162
Although much progress has been made in our understanding of the diagnosis and treatment of ADHD, much has yet to be researched, particularly for adolescents. It is clear that the current diagnostic criteria, although valid for children, may need to be modified for adolescents and adults, to reflect the developmental changes that take place as children approach adulthood. How the subtypes change in the transition from childhood to adolescence and how the patterns of comorbidities change need to be identified more clearly. The recent pressure and incentives that the government has placed on the pharmaceutical industry have increased the number of pharmaceutical company-sponsored studies among adolescents. However, additional studies are required to clarify how medication needs, types, dosages, and frequencies of administration differ among adolescents and adults, compared with children. Given the developmental significance of social functioning, additional studies of the development and evaluations of psychosocial interventions targeting these behaviors are greatly needed. The unique aspects of obtaining adolescents' adherence to treatment are important factors requiring clarification. Lastly, longitudinal studies examining the outcomes for adolescents and adults are required to identify more clearly the course of the disorder and the impact of treatment.
This study was supported in part by the National Resource Center on AD/HD, a program of Children and Adults with Attention-Deficit/Hyperactivity Disorder. The National Resource Center is funded by the Centers for Disease Control and Prevention under cooperative agreement R04-CCR321831.
We thank Edward Zimmerman, Karen Wanatowicz, and Regina Martinez for help with preparation of the manuscript.
- Accepted January 24, 2005.
- Address correspondence to Mark L. Wolraich, MD, Oklahoma University Child Study Center, 1100 NE 13th St, Oklahoma City, OK 73117. E-mail: mark-wolraich{at}ouhsc.edu
Conflicts of interest: Dr Wolraich is a consultant for Lilly, Shire, and McNeil and receives research support from Shire and Lilly; Dr Brown receives research support from Lilly, GlaxoSmithKline, and McNeil, is a consultant for McNeil, Lilly, Novartis, and Shire, and is a speaker for Lilly, Janssen Cilag, McNeil, Novartis, Shire, and Wyeth; Dr Gotlieb receives research support from Shire and Novartis and is a speaker for Novartis and Lilly; Dr Schubiner is a consultant and speaker for McNeil, Lilly, and Shire; and Dr Wilens receives research support and is a speaker and consultant for Abbott, Alza/McNeil, Celltech, GlaxoSmithKline, Janssen, Lilly, Neurosearch, Novartis, Pfizer, Shire, National Institute on Drug Abuse, National Institute of Mental Health, and National Institute of Child Health and Human Development.
- Copyright © 2005 by the American Academy of Pediatrics


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During this hard time of home confinement, Figment has partnered with a local small business @littlelakescollective to bring your kiddos hours of sensory inspired play. Jen Lagunas is a homeschool mama of three. She makes these beautiful invitations to play that keep little hands busy and little minds active.
We've also made kits based on one of our favorite activities at Figment, designing outfits for our wooden mannequins. Ms. Amber has put together a kit of supplies to get your budding fashion designer inspired along with a mannequin of their own.
Please purchase using the links below and pick up Tuesday, March 17 from the Figment Creative Labs courtyard (no contact required!) between the hours of 11AM and 1PM. We have a limited number of kits so purchases must be made in advance of picking up.
Sorry, no shipping. Pick up only.
Each large play dough kit is $39. The Dress Up Mannequin Kits are $25.
Ocean Play Photo not available
Play dough care:
Store in zip top baggies to keep fresh and soft. If dough appears dry, or salt crystals start appearing, add a few drops of cooking oil and knead throughly. This should bring your dough back to life! If cared for properly, your dough should last a minimum of 2-3 months, and often longer!
Playing is learning! Stay safe and have fun.

subset: commoncrawl


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MONTREAL — Stingray Group Inc. has dropped its takeover attempt of Music Choice.
Montreal-based Stingray, which provides music and in-store media, had made the unsoliticited bid for the U.S. company in August last year.
The offer was worth US$120 million.
Music Choice produces music programming and music-related content for digital cable television, mobile phone and cable modem users.
Stingray chief executive Eric Boyko says while the company continues to see benefits in a combination with Music Choice, it's confident in its strategic direction.
Stingray announced Monday a distribution agreement with Altice USA, which will bring 50 Stingray music audio channels and hundreds of music videos from its on-demand catalogue to Altice USA's subscribers.
Companies in this story: (TSX:RAY.A)
The Canadian Press


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Garvin County Park
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- 20 Amp
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Are you passionate about…
Connecting people and ideas together? Making physical distance between people a limitation of the past? Getting your hands on the latest technology? Working for one of best-performing companies and top employers in Canada? Being part of an engaging multicultural environment? Jet-setting? Visiting Canada from end-to-end…. Oh Canada! Constantly learning something new? Why not consider a career with Cisco in the field of Networking?
In a Nutshell, What is Cisco?
Cisco has shaped the future of the Internet by becoming the worldwide leader in networking – transforming how people live, work, play and learn: "Together we are the human network."
What is the atmosphere like day-to-day?
What would you see when you walk in the office doors?
If you are looking to work for a company with locations almost anywhere in the world, look no further than Cisco. As the Networking Academy Manager for Canada, Wadih Zaatar has traveled to more than sixty countries. "I have even visited Canada from end-to-end," Wadih says. His top favorite sight in Canada so far is the picturesque Lake Louise.
There is much more to Cisco than the opportunity to travel. Cisco is on the cutting edge of technology. "You get to play with the latest toys and technologies available!" Wadih raves. For this reason, an open and inquisitive mind is needed. "You should come with the expectation of learning. At Cisco, you face new challenges every day," Wadih explains. "With many jobs, you face the same thing day-in and day-out. At Cisco, there is always something new to learn."
Cisco offers many opportunities for growth and advancement. In fact, it has established the Early in Career Network (ECN) to mentor new hires during their first three years at Cisco. The goal is to create a diverse and inclusive environment that empowers new employees by developing their:
- understanding of Cisco's mission, culture, and vision for the future
- network of colleagues around the world
- knowledge and skills through training and events, and
- career development through a buddy and/or mentorship program
So, if you are a go-getter looking to learn something new every day, this is the place for you!
What makes Cisco a cool place to work?
At Cisco, the belief that customers come first is an integral part of its DNA. That explains why Cisco technology solutions and innovations are driven by some of the hottest trends on the market. Cloud computing, IPv6 (technology that allows computers to communicate over a network), open network environment, video architecture, and virtualization experience infrastructure are just some of the solutions Cisco offers. For non-techies, what does that really mean? All these technologies allow us to connect and truly communicate, making distance a limitation of the past.
Why is this important? Popular theoretical physicist and scientist, Dr. Michio Kaku, describes the importance of the Cisco Human Network like this: "It means that we are going to be together as never before. Exchanging information effortlessly across space and time." Cisco CEO John Chambers says: "Cisco's strategy is a story based on change—the market transitions that affect our customers. Through multiple transitions, the network will evolve from the plumbing of the Internet—providing connectivity—to the platform that enables people to experience life."
What skills will you need?
Be prepared for a challenge! Wadih sums it up in one word, "Dynamic." Independent, energetic, dynamic, performance-driven and passionate people should apply. "This is not your typical nine-to-five, cruising towards retirement position," Wadih explains. Cisco believes in nurturing and training its employees for a lifelong career with the company. What kind of job could you have? Look Here.
Want to learn more about coops or internships with Cisco?
You can start your journey with Cisco today through taking IT and networking courses at schools near you provided by the Cisco Networking Academy. Every year, the Networking Academy teaches over 1 million students worldwide the skills needed to design, build, manage, and secure computer networks. With more than 200 academies across Canada, the Networking Academy delivers classroom instruction, online teaching materials, interactive tools, and hands-on learning to students from every socioeconomic background, so that you can develop the knowledge and skills required to succeed in a technology-driven market.
For more info on jobs right out of University, check out this link.


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I'm going to ignore the fact that you insinuated that I was stupid, again (though I'm glad that you've dropped the tone).
I actually don't think you're stupid, I think you're the latter. I think you are intentionally pettifogging the issue.
I'm going to ignore the fact that, rather than taking just a second to write out what you mean by 'use', you elected to tell me to grab a legal definition of 'use'. ("The fact of being habitually employed in a certain manner.", which is still quite vague, and most certainly is applicable in my two examples).
And I am going to ignore that you are still trying to pettifog the issue. By the amount of downvotes you have, and upvotes I have, I am going to have to assume my message is clear.
And I'm going to ignore the occurrences of you refusing to address the point and going off on some tangent.
And I am going to ignore that you keep saying I am off point, or not making a point, when my point has been repeated a million times like I am a fucking parrot. No living thing has the right to force you to use your body in order for it to survive. This is the basic fundamental bodily rights and autonomy that every person is granted.
Firstly: you really need to write down a definition of the word 'use' as you are intending it. please.
We're not playing this game, it's clear what I meant.
Secondly: I have yet to state that I support or oppose abortion. My argument is and has always been that abortion is not a women's rights issue. I find an argument on whether or not a fetus is alive to be vacuous, because of the horribly ill-defined meaning of human life. I am also not going to present an argument on what is or isn't moral, because I have yet to see a justification for any moral action from a logical standpoint.
The logical standpoint is clear, and it's why abortions are legal. We can not, and we will not, force people to use their bodies in order to keep another living being alive.
Thirdly: It's important to note that, through inaction, the baby will survive. That's a highly integral nuance. You have to go out of your way to kill it.
It's not about killing a life, it's about exercising the mother's right to not be forced to keep another living thing alive using its body. It sucks that it will end up with the death of a "potential human life", but that's the way it has to be. The only other option is to tell the woman that her body is no longer hers anymore for the duration of the pregnancy. And that's not something the law is prepared to do, nor should it.
If a horrible car accident happened, and, after surgery, you and someone else shared a lung, do you reserve the right to kill the other on merit of them using your body to survive? Does the permission to commit murder go to the person whose lung is being used, who wasn't responsible for the accident, or some other criteria?
You're right, it's a shit analogy. One that needs more information. Who's lung was it originally? Why wasn't I asked before I was forced to share a lung? If it was my lung, and they were only alive because they were sharing it? Are we conjoined and sharing a lung now, or did they illegally remove my lung without my permission to keep someone else alive?
Additionally, I made the assumption that you were downvoting my replies because they would receive exactly one downvote within a minute of my posting, and then no others. I think I am validated in assuming that your character was such that you would do that, considering your first reply's douchiness, and the fact that you continually claimed that your arguments were objectively true. That being all I know about you, I believe my assumption was made on very solid ground.
Assumptions you make about a person you don't know are never made on solid ground. Welcome to the internet.


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The Women's Business Enterprise National Council and WEConnect International Introduce the Women Owned Business Logo
Jun 25, 2014, 09:00 ET
WASHINGTON, June 25, 2014 /PRNewswire/ -- The Women's Business Enterprise National Council (WBENC), WEConnect International and Walmart have joined forces to establish a unique logo for retail packaging of products from women-owned businesses. This new logo will bring consumer recognition of products provided by women-owned businesses on store shelves both in the US and international markets. Women-owned businesses that are WBENC and/or WEConnect International certified will be eligible to display the logo on their product packaging. Walmart's collaboration with WBENC and WEConnect International on the new logo is aligned with their overall strategy and focus on women-owned businesses.
In September 2011, Walmart launched its Global Women's Economic Empowerment initiative, using its unique size and scale to lift women around the world. As a part of this initiative, Walmart has committed to source $20 billion from women for the US business and to double sourcing from women internationally by the end of 2016. In further support, Walmart has collaborated with the Women's Business Enterprise National Council and WEConnect International to establish a logo to help consumers easily recognize products from women-owned businesses in stores.
Women-owned businesses contribute over $1.3 trillion dollars to the US economy and women are responsible for over 80 percent of the consumer decisions globally. Creating awareness of these products can result in sales growth, increased consumer knowledge and loyalty. Both WBENC and WEConnect International focus on women's business growth, which will be a natural outcome of the visibility and promotion of this logo.
"At Walmart we are committed to empowering women and impacting women-owned businesses from around the world—and so are our customers. In fact, we recently conducted a survey that found 90 percent of female customers in the US would go out of their way to purchase products from women, believing they would offer higher quality," stated MiKaela Wardlaw Lemmon, senior director of Women's Economic Empowerment at Walmart. "We hope our collaboration with Women's Business Enterprise National Council and WEConnect International will make customers around the world more aware of great products from women-owned businesses, and help these women continue to grow their businesses."
Pamela Prince-Eason, president and CEO of WBENC and Elizabeth A. Vazquez, CEO and Co-Founder of WEConnect International, recognize the leadership and innovation that Walmart has brought by helping to develop the symbol as well as providing the research to support the launch and selection of the logo. Walmart will have products on their store shelves with the new women-owned business logo by September 2014. They look forward to seeing many retail companies stocking their shelves with these branded products in the near future.
Photo - http://photos.prnewswire.com/prnh/20140625/121426
SOURCE Women's Business Enterprise National Council


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Gianni Infantino to revive 'blocked' Women's World League
Infantino, who was recently re-elected as president of soccer's global governing body, told delegates at the FIFA Women's Football Convention that he intends to revive "blocked" plans for a global women's club competition.
The proposal forms part of FIFA's bid to double worldwide participation in women's soccer to 60 million by 2026, while finding a female equivalent to the men's annual World Club Cup remains high on the agenda of both Infantino and Fatma Samoura, FIFA's first female Secretary General.
The Women's World League concept was originally proposed as an annual competition featuring 16 of the top national teams, plus four regional leagues and a system of promotion and relegation.
Infantino said: "I proposed two years ago the creation of a women's world league because national team football is the catalyst of women's football and we will see this with the World Cup here in France.
"Unfortunately, this project was a little bit blocked, let's say, or put on hold. I can announce that I will put it back on the table, with even more strength and force because we need to promote women's football.
"That is why we need to bring back, in football, [the possibility of] the Women's World League, and the World Club Cup for women.
"We need to have proper and own identity for women's football and this can only be created if we have a dedicated section within the [FIFA] administration, [which] has to push the development of women's football.
"Football is a very male-dominated and macho-dominated sport, but it is moving and changing. The best is still to come, and will come soon than many things."
His comments come amid heightened debate over the apparent inequality between men's and women's soccer, highlighted by the gulf between prize money allocated at this year's ongoing Women's World Cup and the men's tournament last year.
Whereas the men's tournament in Russia included US$400 million in prize money, a total of US$50 million has been allocated to women's event this summer, of which US$30 million is prize money and another US$20 million was allocated for the 24 participating team's tournament preparations.
Infantino continued: "We are investing as well in women's football. When it comes to the prize money for the World Cup, from US$15 million to US$50 million, is it enough? No. Can it do better? Yes. But it's a step."
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Walnut as well all know is a portion of healthy food and comes with a lot of advantages. However, what most people are ignorant about is that walnut is not all good; it also has its cons. In our initial articles we had already laid stress on walnut benefits and side effects – however, today we are going to move beyond as emphasize on walnut oil health and walnut oil health benefits.
Thus, many elaborate and question the walnut oil uses. Walnut oil can benefit one in many forms; therefore this article is going to stress on some of those beneficial effects that walnut oil has:
Walnut oil health benefits
Fight against fungal infections
Walnut oil is an important factor in fighting fungal infections. All one needs to do is put cold compressed in that very region. One can also add a pinch of tea tree oil to the walnut oil. This should be done as often as one can. This oil is also good for skin, especially when one has pimples.
Walnut oil for skin
Walnut oil and skin go hand in hand. This is so, as this oil contains properties that enhance one's youth and makes their skin glow along with looking younger. It is useful because it consists of Vitamin B and Vitamin E. One can also make a pack when mixed walnut oil with honey. The pack rejuvenates one's skin and keeps it young!
Does away with dark circles
We all know that dark circles are very common and usually arise due to the lack of sleep. Walnut oil is very effective in terms of reducing these dark circles. All one is required to do is to gently massage this oil below the eyes. Once this is done every day, a couple of times a day – one will see the difference and a glow on their face!
Walnut oil for hair
One of the walnut oil health benefits is that it is very good for the hair. It fights hair fall – since it contains omega 3 fatty acids which are very good to prevent damage to the hair. Apart from just hair loss, walnut oil also aids in fighting dandruff. This is done as the oil helps to maintain the scalp and remove all oil from it. Thus, due to walnut oil one will find themselves with an oil-free scalp. Finally, walnut oil also helps in promoting hair growth as it contains a high amount of potassium. This property is very essential in promoting hair growth. Thus! Walnut oil is very crucial for good hair.
Also Read :- Innumerable Walnut Benefits and Side Effects to Remember
Reduces the risk of cardiovascular diseases
One of the walnut oil health benefits is that it replenishes the chances of cardiovascular diseases. Consuming large amounts of walnut oil will help reduce cholesterol levels – thus, also aiding in reducing the chances of cardiovascular diseases. Thus, one is suggested to include walnut oil in everyday foods and diet!
Can help one sleep
Walnut oil helps provide one a good night's sleep. It is rich in melatonin – this is basically a neurotransmitter chemical which helps one to sleep. Apart from just this melatonin also removes stress and anxiety thus making sure one sleeps well and easily
Walnut oil and weight loss
Walnut oil health benefits are many and a prevalent one being attaining weight loss. This oil is very good at cutting belly fat. In fact, walnut oil salad dressing is a great way to lose weight. Eat salads with a pinch of walnut oil and find your body getting toned and healthy. Thus, walnut oil is very active in terms of losing weight. People who are obese or slightly overweight should add olive oil in their diet and see the difference!
Boosts immune system
Walnut oil is highly essential in making the immune system better. They contain antioxidant and antibacterial properties which help the immune system to work better. Thus, if you are someone who tends to fall ill fast – then include walnut oil in your diet and you will notice the difference!
Cooking with walnut oil
Walnut oil as we all know is very healthy and hence cooking with walnut oil is a very healthy lifestyle that one can adopt. The taste is very good to add onto not only salads but fish, steaks and even pasta! Thus, walnut oil can be used in various ways in different dishes and it is very healthy!
Side effects of walnut oil –
Heart Health
One should talk to their doctors before using this oil internally, as the blood pressure lowering effects of this oil can create complications with other medications. Thus, one should consult their doctor before taking this oil
Blood sugar
Even though walnut oil is said to be very good for diabetic people, however, the oil can lead to low levels of blood sugar if used along with other drugs. Thus diabetic patients should be very cautious about using walnut oil and should consult their doctor before doing so
Skin inflammation
Walnut oil can very definitely cause skin inflammation. Thus, if one has sensitive skin then apply very little of the oil on your skin and wait to see if there is a certain rash developing. Thus, if one has sensitive skin then this oil may not be right for you!
Hence, above have been laid down walnut oil health benefits and the various ways in which this oil can help one to cope with low immunity, skin infections, hair loss and damage, and most importantly how to lose weight. However, apart from just the health benefits, we have also explored the side effects of walnut oil. Thus, with every good also comes the bad. If one uses olive oil every day, it certainly is good – but try staying away from the side effects. We hope the article came to much use and was a good read! Thus one should explore both the benefits and side effects of walnut oil.


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Gameplay and Prizes
The gameplay is pretty simple. One can bet from one to 150 coins – just by selecting the amount you wish to bet, choose which paylines you will launch, press "spin," and away you go! One can regulate the total amount you bet in the course of the game, and it may be smart to do so when you hit a winning streak – the money can mount up.There are more than 33 profitable combinations feasible within this game; thus, you will discover lots of chances to win prizes. It is not just the regular payouts which are worth your time, nevertheless, Mr. Cashback also offers some fantastic bonus features.
Features and Bonuses
Mr. Cashback is ample with his winnings in the main game and incredibly generous with his bonus features. You will discover quite an array of bonus features available to players within this game, and they happen quite regularly.
- Mr. Cash Back Free Games.
Is a Free Spins feature. Striking three or more Mr. Cash Back symbols anywhere on the reels will activate the Mr. Cash Back Free Games round. Players will get 12 free games with a default multiplier of 2x. Also, freezing wilds appear randomly on the reels during free spins.
- Mr. Cashback Feature.
The Mr. Cashback feature is active only during the main game. It's activated when a single win line doesn't win at least one time for every 50 spins completed. Each time a particular win line doesn't generate a winner for 50 spins, the line bet is refunded times 50. It's basically getting your money back!
- Gamble feature.
Mr. Cash Back also has a gambling feature, and a single win can activate it. Players have the option to take their win, or even risk it for a higher prize. They have to choose either red or black from a deck of cards, if they presume the color of the next card drawn, they'll be paid at odds of 2:1. They are given the option once again; they can either obtain their prize or gamble again. If they are lucky, wins can amount to a massive £5,000.
- Wild Card Feature.
Mr. Cashback himself is the wild card. He will stand in for virtually any of the other logo and also hand over the jackpot. Secure five Mr. Cashbacks you will be able to win 7,500 coins.


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Glass House | Fun House | Rock Climbing Wall
Captain Hook's Play Station – Fun House| Scooby Shack – "Fun" House
Captain Hook's Play Station – Fun House| Scooby Shack – "Fun" House
FUN HOUSE (with rotating barrel)
The tricks never end in the Fun House. From moving floors too spinning poles fun house mirrors and exiting through a huge rotating barrel
Race to the top – Towering Faux Rock Walls has foot and hand holds for adults and kids. Climbers wear a secure harness as they scale the walls.
Captain Hook's Play Station – Fun House
Dora, Diego and a cast of others make this Sea Pirate Fun House an exciting adventure to explore and yes … it's full of exciting surprises, climbs and slides along the way!
Classic Amusement Does it All - Rides, Inflatables, Concessions


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What Kind of Conference is Right For You
I once asked a parent whose daughter was a terrific goalkeeper where she was thinking about attending college. He told me three schools — an Ivy League in an urban area, a top-ranked ACC university out in the middle of nowhere, and a mid-size urban-based Patriot League college that excelled in very specific majors.
I thought to myself, wow, they've either done a nice job and cast a broad net or they have no idea what to do. This family was looking at three totally distinct schools catering to three very different kinds of athletes, which made me realize many parents are not honest about who their kids are.
Why is this a big deal? Because if you don't know what kind of school is best for you, you won't know the timing or the steps you need to take.
Follow these rules of thumb when planning your school selection.
- You want to go to a Power 5 Conference.
These Power 5s are the ACC, the SEC, the Big 10, the Big 12, and the PAC 12. They get the best athletes and they get them the soonest. They're looking at who is on the national team, at national training centers, or attending regional ID camps. These kids are getting discovered in 8th and 9th grade.
If you're looking at a Power 5 school as a junior, it's probably too late. There is an exception. If another athlete decommits, there's an opening. But that's not a strategy. That's a needle in a haystack.
2. You want to go to an Ivy League
The Ivy Leagues are HIGHLY academic, even as D1s (and they're all D1s). They can't and won't make a move on you unless you have a 1300 SAT. Do you know how to prepare for that? This is one of those times when I recommend studying for the test. Unfortunately, if you're a junior and you've not taken the SAT yet, or your numbers aren't as high as they need to be, you're probably out of luck. You may get a second chance that an academic school takes a look at you if you KILL it on the retest of the SAT, but if you're still debating whether you can raise your scores, then your pecking order doesn't start with the Ivies. But at least you've done the legwork to know that.
3. You want to go to a Patriot League school


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Two lights in one, day and night!
This light is great for those pet birds that experience "night fright". The LED UV blue moonlight provides a calming atmosphere.
The FeatherBrite Full Spectrum Light fits most cages.
Lightweight and simple assembly. Attach the stainless cage adapter to light and push between bars. Easy!
Light measures 9 inches x 9 inches with legs attached and 18 inches long with wire extender. Weighs approximately 3 lbs.
The safety wire extender helps keep the electrical cord away from the back of the cage.
Four bird safe, non-toxic powder coat colors to choose from!
A FeatherBrite 16w LED full spectrum bulb is included in all lights.
A blue UV LED bulb is included This new bulb can be used 24 hours per day since it is only 1.5 watt which produces low UV's and is safe for your bird.
There are two electrical cords with off/on switches. Both can be operated with a timer.
The FeatherBrite Bulbs
The FeatherBrite 16 watt, 5500k, full spectrum LED bulb is perfect for all kinds of birds, finches, parrotlets, parakeets, love birds, cockatiels, conures, senegal parrots, African Greys, macaws, amazons, they love it! There are no UV's in the daylight bulb so you can use it during daytime hours and not worry about getting too much UV exposure. The LED UV Blue bulb that is included with our light provides the health enhancing low dose UV's that parrots and birds need.
Safety Features:
Our lights have a non-toxic powder coat finish available in four colors. The light shade is aluminum. We use a ceramic socket. A wire safety arm is attached that helps keep the electrical cord a safe distance from the cage and our lights are assembled with UL listed components. The safety wire arm and hardware is stainless steel. Our cage attachment is stainless steel also and very easy to attach to all types of cages. The legs can be attached front to back or left to right and you can even face them inward for the smaller cages.
The Universal Bird Cage Light attaches easily without the use of hardware. All of the FeatherBrite lights are handcrafted (patented design) with superior workmanship and quality. Made in the USA.
Please note: You and your pet's safety is FeatherBrite's top priority. To prevent damage to the light bulb or electrical cord, remove and unplug the light from the top of the cage before your bird comes out to play.
Compare with the FeatherBrite Universal Light.


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A regular feature here on The Daily Driver Project is the "Street Spot." We love seeing vintage cars as daily drivers, out on the streets where they belong. When we see a vintage car worth sharing, we'll post it as a Street Spot. Sometimes it will be a beauty, sometimes it will be a beater, but then again – even the beater cars are beautiful to us!
Sometimes you just get lucky and roll-up on a cool ride out cruisin'. That was the case when I ran across this great looking Fleetline.


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Austin Powers: International Man Of Mystery
Director: Jay Roach
Actors: Mike Myers, Elizabeth Hurley, Michael York, Mimi Rogers, Robert Wagner, Seth Green, Fabiana Udenio, Mindy Sterling, Paul Dillon, Charles Napier, Will Ferrell
Genres: Comedy, Crime
Country: USA, Germany
Release Year: 1997
Duration: 94 min
Storyline: Austin Powers is a 60's spy who is cryonically frozen and released in the 1990's. The world is a very different place for Powers. Unfortunately for Austin, everyone is no longer sex-mad. Although he may be in a different decade, his mission is still the same. He has teamed up with Vanessa Kensington to stop the evil Dr. Evil, who was also frozen in the past. Dr. Evil stole a nuclear weapon and is demanding a payment of (when he realises its the 90's) 100 billion dollars. Can Austin Powers stop this madman? or will he caught up with Evil's henchman, with names like Alotta Fagina and Random Task? Only time will tell!
YOU ARE WATCHING: Austin Powers: International Man Of Mystery
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