Attention deficit hyperactivity disorder (ADHD) is said to be one of the most commonly occurring behavioral conditions in children and young individuals up to the age of 18 years. It has been estimated that the worldwide prevalence of ADHD is approximately 5% of children and young adolescents(Bullington and Fagerberg, 2013). In this work of research, ADHD has been focused upon in order to delve deep unto its care services. Both the holistic care and specialist services in relation to ADHD are being discussed elaborately in this write-up with adequate evidences. Moreover, why current guidelines do not always consider the complexity of individual cases has been evaluated alongside the complexity management provision. How specialist services are designed for meeting the varying needs of the patients have also been looked into; whereas the way of services working together for ensuring patients receive individualized seamless care has also been critically discussed. The research study is also about highlighting the strengths of and gaps in current specialist service provision which form a significant part in the critical discussion of the issue
Holistic care can be defined as a comprehensive model of caring. When it comes to the philosophy of holistic care, it can be found that the whole concept is based on the idea of holism which emphasizes the fact that human beings as a whole are greater than the sum of their parts, and that mind and spirit do affect the body(Berg and Sarvimäki, 2003). In this regard, holistic care is regarded as a behavior that does recognize an individual as a whole in its entirety in terms of acknowledging the interdependence amongst one’s biological, social, psychological and spiritual aspects.
As far as attention deficit hyperactivity disorder (ADHD) is concerned, it has been defined by National Institute for Health and Care Excellence (NICE) as ‘a heterogeneous syndrome characterized by the core symptoms of inattention, hyperactivity and impulsivity’(National Institute for Health and Clinical Excellence, 2008). It can be mentioned in this context that individuals afflicted with ADHD do not necessarily showcase every single feature of the disorder. While hyperactivity and impulsivity are dominant in several cases, other features are often subdued with inattentiveness playing havoc in some cases as well. Individuals with the symptoms of ADHD tend to have a condition which is found to be persistent throughout the formative years; and this condition is the reason that puts them at the risk of low self-esteem, anti-social behavior, mishaps, and academic underachievement to a large extent(Porter, 1997).
There are several symptoms of psychiatric disorders and for ADHD, the symptoms are inclusive of –
· Inability to pay attention or inattentiveness to its extremity
· Easily distracted
· Failure to complete tasks
· Losing things randomly and often unnecessarily
· Impulsivity to a great extent
· Not regular with a definite activity
· Excessive talking
· Unnaturally excessive motor movement
· Inability to sit for a long period of time
The symptoms are prevalent and often go unnoticed because almost every child is naughty and does certain things which are intrinsic to childhood. Furthermore, as the ADHD symptoms tend to start before the age of seven, they are often confused with regular child activities and behaviors; which lead to late diagnosis and treatmentMorgan and Yoder, 2012). The difficult most part in the assessment of ADHD is that there are aplenty conditions that tend to cause these symptoms. As far as the causes of ADHD symptoms are concerned, they can be listed as:
Genetic, Birth issues i.e. premature birth, low oxygen, fetal alcohol syndrome etc., Environmental, Allergic reaction where ADHD symptoms occur due to intolerance of food additive or sugar or lactose etc., Hyperactive thyroid, Abusive family history, Auditory processing or developmental vision problems, Children with learning disabilities i.e. dyslexia, Depression or bipolar disorder, Hypoglycemia in children, Intellectual giftedness i.e. children with IQ over 130 or more(Henderson, 2002).Amidst the range of causes, ADHD is significantly considered to be a disorder caused by genetic cause as more than 30% of ADHD children have been found to have associations with elders with ADHD. It has been reported that ADHD children have at least one parent with similar problems during their childhood.
Arguments have been made regarding causes such as allergies or environmental conditions. Furthermore, abusive history i.e. domestic violence, sexual abuse, physical abuse etc. are also quite common and therefore connected to the ADHD issue amongst children. Comparing to the major reasons, ADHD symptoms concerning lead poisoning, hypoglycemia, hyperactive thyroid are considered less common. It is to be mentioned in this regard that depression, bipolar disorder, hypoglycemia and others do not actually cause attention deficit hyperactivity disorder (ADHD) but tend to produce symptoms that are similar to ADHD symptoms.
While physicians can detect lead toxicity, iron deficiency, hypoglycemia etc.; psychologists are responsible for assessing genetic influences, domestic violence, intellectual giftedness, environmental influence etc. by means of intellectual testing alongside a thorough checking of social history(Strandberg et al. 2007). In addition to these, allergists with specialization in the definite behavioral reactions to allergies can very well determine any sort of allergic reactions in connection to ADHD.
As ADHD is considered to be one of the most common as well as challenging childhood neurobehavioral disorders, it is necessary to treat this disorder with utmost care and knowledge. About one third to one-half of the patients with ASDHD are said to have persistent symptoms into their respective adulthood which indicates the seriousness of the disorder. It has been found from studies and researches that the prevalence of attention deficit hyperactivity (ADHD) in USA is estimated around 5-11% that is representative of a whopping 6.4 million children nationwide. This is to be mentioned in this regard that the variability of ADHD prevalence all over the world, including the United States happens due to several reasons that adversely affect the accurate assessment of children and the young adults. The obstacles are the reasons for ADHD’s under-diagnosis, misdiagnosis and under-treatment.
Scientific articles have been reviewed in order to search for factors that have the impacting authority over the respective identification and diagnosis of ADHD. Articles demonstrating the naturalistic consequences of disorder diagnosis and treatment have also been examined. The results have repeatedly revealed that multiple factors have significant impact in the cases of ADHD identification and treatment and those are largely inclusive of parents, family, healthcare providers, teachers, environmental aspects and others. As a lack of understanding regarding ADHD and the importance of its diagnosis and treatment is prevalent amongst many members of the community; ADHD looms large as a socio-psychological danger. More basic and clinical research does have the capacity of improving diagnosis methods alongside methods of information dissemination. Strong partnerships between clinical authorities and care givers and patients can be effective in reducing the adverse impacts of this psychological as well as behavioral disorder.
Role of parents
Parents play a crucial role when it comes to the early recognition of behavioral issues in their children which have the possibility of prompting them in seeking medical help. Parental perception can be of biggest factor for ADHD afflicted children regarding medical management requirement after accepting the reality and intensity of the disorder. Often parents are found to be not seeking assessment for ADHD and the reasons can be listed as i.e. dietary factors, limitations of educational settings, having a higher threshold of behavioral tolerance with concern to not considering child behavior as unnecessary or burdensome. Furthermore, the respective motivation and the ability of assessment seeking can be impacted by certain psychological stressors i.e. fiscal issues, having multiple children, uncertainty regarding the ADHD afflicted child’s behavioral patterns.
Studies have revealed that parental income and the individual type of health insurance do have the influence over the diagnosis timing of ADHD in the United States as the specialist services for the child evaluations are tad expensive and hefty. Parental stress can also negatively affect the children with ADHD symptoms. It is known from the research studies that parental exposure to wrong or negative information about ADHD, largely from non-healthcare professionals and ever active social media can cause delay in the ADHD identification and treatment. Different cultural and ethical backgrounds often cause the parents to hold different views and perceptions of the behavioral norms which tend to bypass the inappropriate behavior patterns of indications of a clinical disorder such as ADHD.
In this regard, it is necessary to mention that healthcare professionals must be fully aware of differing cultural beliefs and ideologies for serving the purpose of unifying parental beliefs alongside clinical psycho-education and recommendations regarding treatment. It can be noted that several immigrant communities consider the psychiatric diagnosis of ADHD in close association with isolation and societal exclusion; whereas hyperactivity or streaks of impulsivity in boys is regarded as typical gender preferred behavior by parents which should not be the case.
The family plays a pivotal role in the management of children with attention deficit hyperactivity disorder. The parents and teachers must maintain a level of trust and communication between themselves for this has a vital role in the early diagnosis of ADHD. Effective communication between teachers and parents is essential for early as well as appropriate identificationand diagnosis of children at risk. Strong trusting relationships between parents and teachers helps in sharing information about a child’s functioning and also any sort of concerns about symptoms. In addition to this, parents of ADHD afflicted children are said to have a higher probability of having the diagnosis themselves; as lack of diagnosis amongst parents can lead to heightened risk of familial conflicts and negative interactions between child and parent to an increasing extent.
Role of healthcare providers
It has been revealed from studies that the limited access to mental health clinicians happens to result in the majority of the children being identified, diagnosed as well as treated by primary care physicians in the United States. Therefore, it is evident to mention that access of the public, children and their respective families to healthcare providers along with medical research findings play influential role in the early diagnosis and recognition of ADHD(Taylor et al. 1996). Moreover, limited reimbursement meant for mental health care can also be counted as a prominent factor in the ADHD diagnosis where complex cases are in requirement of more clinician time.
In this context, detailed family, educational and prenatal histories are said to be significant importance when it comes to aiding in the ADHD diagnosis. Evaluation of children for attention deficit hyperactivity disorder (ADHD) necessarily calls for questioning regarding ADHD symptoms in siblings and parents; because it has been researched and proved that parents of ADHD afflicted children are four times more likely to have symptoms of ADHD themselves, either in mild or severity(Young et al. 2008).
There has been proposed revision of the already specified diagnostic criteria in DSM-5 for ADHD which is not against the fundamental concept of attention deficit hyperactivity disorder (ADHD). The validity and accuracy of ADHD diagnosis is often questioned concerned its lack of standardization and biased attitude(Hamed et al. 2015). The whole system concerning ADHD diagnosis to management of the disorder is open to interpretation as different medical or non-medical professionals come up with varying opinions and perspectives. Despite retaining the DSM-IV wording of all previous symptoms of ADHD, DSM-5 would be containing more instances and examples which would help in making the disorder criteria more accurate for children, adolescents and adults likewise(.
The age of onset would be varying too from the earlier specification, from 7 to 12 years; that would be invariably leading to changed subtyping of the disorder. There would be no exclusion criterion concerning the pervasive developmental disorders and that definitely has nothing to do with the core concept of the disorder. The suggested changes are being made in order to cause increase in the ADHD prevalence because the necessary revisions and new validations make way for betterment in the diagnostic, rating and treatment provisions of ADHD(Dalsgaard et al. 2014). Furthermore, the continued care giving processes would be benefitted from these changes suggested.
Role of educators
The growing years of children should be having a supportive environment around and thus, the primitive years of life are of significant value for the children in concern. Children tend to spend a considerable portion of their lives in school which in turn make the teachers and the concerned school infrastructure extremely crucial as well as influential for overall development along with the ADHD diagnosis and recognition(Saloner et al. 2013). A teacher’s report of a child’s behavioral patterns is often considered to a large extent in case of the clinical assessment of ADHD; although the teacher ratings of the ADHD symptoms often have been countered with limitations regarding discrepancies amongst Afro-American and non-black students.
The teacher ratings of child behavior is considered valuable in the assessment of ADHD and thus, the mental health community leaves a significant imprint during its course of providing adequate training and support for educationally based professionals in the ADHD children recognition and management accordingly(Tirosh and Cohen, 1998). It is thus essential to mention that the attitude of schools and the teachers towards the neurobehavioral disorder ADHD and the respective incorporation of early intervention efforts does have a remarkable impact on both the recognized children and their families. In this regard, the mutual connection between the parents and the teachers is deemed necessary and vital.
The world is in a constant flux and so is the treatment for ADHD. The study of Attention Deficit Hyperactivity Disorder (ADHD) is said to be in its primitive stages and there is a whole new lot to be discovered. As attention deficit hyperactivity disorder (ADHD) is largely considered to be a developmental disorder with the impeding properties towards every stage of child’s functioning throughout life(Dalsgaard et al. 2014). The afflicted children are often prevented by this disorder from reaching their full potential respectively. The offered interventions are many and can be listed as:
· Multidisciplinary approach to the ADHD management with teams meeting weekly
· Behavioral support groups
· Personalized and customized school observations and suggestions
· Clinical nurse specialist sessions on an individual basis
· Medication reviewed by specialist team
In this regard, the specialist attention deficit hyperactivity disorder (ADHD) service within the developmental paediatric team of St. George’s University Hospitals can be referred to. This service is found to be supportive of parents and children throughout the procedure of assessment, diagnosis, management and treatment of ADHD. Moreover, there are provisions for follow up care specially for children under the service till the children are of older age for transitioning towards adult services(Polanczyk et al. 2010). Moreover, due to a high degree of comorbidity between ADHD and disabilities of learning, teachers are said to be great contributors in the daily management of children diagnosed with ADHD. It has been revealed that early recognition coupled with treatment have the authority of preventing the development of more serious and complex psychopathology during the time of adolescence and adulthood.
It is of utmost importance to identify as well as appropriately manage the disorder in order to mitigate the invariable effects of ADHD. Moreover, joint working among educational, healthcare and social care organizations is a prime requirement for dealing with ADHD individuals with efficiency(Tirosh and Cohen, 1998). There can be several reasons regarding why a child requiring to meet the diagnostic criteria for ADHD remains unidentified as well as untreated such as:
· Unacceptance from some physicians regarding the fact of existence of attention deficit hyperactivity disorder (ADHD) as a separate entity
· Lack of awareness amongst parents and elders of the condition for considering diagnosis of ADHD
As far as ADHD is concerned, it has the capacity of impacting many areas of a child’s life and therefore, a comprehensive package of care is essential for the afflicted children and their families which would be invariably inclusive of both educational and health aspects. In order to attain the care package - coordinators of special educational needs, school nurses, multidisciplinary specialist ADHD teams, pediatrics, forensic services, child and adolescent mental health services, parent support groups and others need to be involved effectively (Levinson, 1990). In addition to these, there should be regular review and communication between the healthcare professionals and care giving agencies to ensure utmost care to the ADHD patients.
In accordance with etiology, attention deficit hyperactivity disorder (ADHD) can be considered as a neuropsychiatric disorder. Although medication has found its favor in numerous cases of ADHD, it can invariably be put forward that optimal treatment of ADHD happens to require integrated medical as well as behavioral treatment(Magon et al. 2014). In order to ensure patients receive individualized seamless care, the specialist services are designed accordingly and often customized depending on the needs of the individual patients, both children and adult accordingly.
Although stimulant medication is common amongst the treatment of ADHD symptoms, its usage in children with ADHD has recently been considered. It has been found that stimulant medications such as methylphenidate, popularly known as Ritalin, Concerta in trade language helps in causing improvement in the cognitive attention and behavior(Kieling et al. 2010). Furthermore, children with ADHD have been examined to display increased reading results following methylphenidate treatment; while the treatment is said to have played contributory role in the improved word and non-word decoding accuracy.
As far as Interactive Metronome Training is concerned, it can said to be a relatively new intervention for ADHD afflicted individuals. This indicates a computerized version of a simple metronome which is regarded as helpful with children with ADHD(Pliszka, 2007). As motor planning and timing deficits are frequent among ADHD patients with regard to problems with behavioral inhibition; it is considered plausible for the interventions such as IM training to improve both the motor planning and timing abilities directly. The deficits are often alleviated with stimulant medication treatment and therefore, this alternative can be sought after by the professional care givers. In this context, Sensory Integration Training can also be mentioned. Sensory Integration (SI) therapy is not essentially a treatment for ADHD patients but is delivered by occupational therapists as an intervention for SI dysfunction which is often observed during severity of ADHD(Wilens et al. 2002).
Furthermore, Cerebellar Training can also be sought out which are nothing but brain-focused training, inclusive of exercise programs with cerebellum stimulating capacity. Another approach is Antimotion Sickness Medication which is said to be helpful in children with ADHD. The theoretical angle behind this approach is that ADHD and inner ear problems are closely associated on the account of inner ear system’s role in maintain balance and co-ordination(Voeller, 2004). The advocates of this particular approach tend to recommend a cocktail mx of medications, ranging from antimotion sickness medication to stimulant medications. This is to be added in this context that all these approaches mentioned are yet to be tested and examined in the rigorous manner in terms of making a clear cut conclusion about their validity and efficacy in treating the ADHD symptoms with effective precision(Shaffer et al. 2001).
The specialist teams tend to decide the actual medications for the ADHD patients as per their benefits; because every case is different and therefore needs special care and service. Both stimulants and non-stimulants are part of effective medication that help the ADHD patients in feeling more relaxed and alert. For children with ADHD, the effects can be visible in form of reduced hyperactivity and improved attention (Langley et al. 2010). While some medications are short acting, others are more or less longer acting i.e. over 8-12 hours or an all-day effect, depending on the varying needs of ailing individuals. It is to be added in this context that majority of the medications are not self-curing the ADHD symptoms as they happen to act on certain chemicals in the brain called ‘noradrenaline’ which seemingly affect the brain parts that have the capacity of controlling attention and organizing behaviors. Those agents have no curing capacity of ADHD but are helpful in controlling the symptoms with regard to inattentiveness, impulsivity and hyperactivity(Accardo et al. 2000).
Recognizing the complexity of service provision for attention deficit hyperactivity disorder (ADHD), the development of consensus can be referred to which was done with the objective of defining best practice. A seven-person steering group, inclusive of specialists in child psychiatry, lead pharmacists, primary care specialists – can be found to have dedicated towards the commissioning and delivery of a service for ADHD(Voeller, 2001).
Care coordinators should be always available for the purpose of assessing both the clinical and non-clinical needs of each patient and accordingly enable appropriate effective care. The key focus of the care coordinator can be regarded as the provision appropriate access to the support services(Coghill, 2015). As the care coordinator happens to play a central contact point for the patient, family, carer and any member of the multidisciplinary team; he/she must have specialist ADHD knowledge, valid clinical background in ADHD, independent workability, effective understanding of treatments and their respective side-effects along with the capacity of patient assessment and appropriate referring. It is to be mentioned in this context that the role of the care coordinator must be taken into serious consideration at the point of commissioning the service.
As far as commissioning ADHD services is concerned, it must be inclusive of hassle-free transition amongst young individual, adolescent and adult services. It has been observed in the UK respect that the transition from services for young people often becomes an issue due to lack of separate adult services in many areas of United Kingdom. Individuals diagnosed with ADHD symptoms that often persist into their adulthood are mostly cared for by generalist community mental health teams and not specialists(Asherson et al. 2013). Moreover, often the young adults are at the risk of getting no continuous care due to ineffective transition services. It is to be put forth in this context that attention deficit hyperactivity disorder (ADHD) is a long-term condition which needs thorough care and treatment over many years, depending on individual patient requirements(Polanczyk et al. 2010).
As per the National Health Services (NHS) recommendations, there is an urgent and immediate requirement of engaging primary care too because the patients need primary care first of all things. It is the responsibility of the primary care team for ensuring that children with possible symptoms of ADHD are as soon as possible referred for diagnosis to avoid any sort of determent of treatment(Arnold, 2002). The general physicians must be assisted accordingly by the primary care team for making sure the appropriate management of the ADHD patients throughout the condition. In this regard shared-care pathways can be mentioned as they have proved to be useful both in ensuring apt assessment of the ADHD patients alongside prescribing necessary medication. As far as the appropriate support provision is concerned, it should be containing education, training, tools of communication, clinical guidelines and last but not the least care pathways(Selimen and Andsoy, 2011).
Nursing resources are important in dealing with the ADHD patient treatment. Specialist ADHD nurses act as vital resource when it comes to the role of care coordinator. It is the duty as well as the responsibility of the ADHD nurses to act as the communication bridge between clinical and community agencies and family for serving the purpose of ensuring defined clinical outcomes(American Academy of Pediatrics. 2001). Their duties are invariably inclusive of monitoring ADHD afflicted children and adolescents alongside providing adequate support to the respective families.
It can be added here in consideration of the development of new working arrangements in NHS, the publicly funded national healthcare system of England that there is availability of evidence-based Integrated Care Pathways (ICPs) for aiding in the effective management of ADHD, which can also be used for the cause of facilitation of implementation on a local basis. As the prevalence of attention deficit hyperactivity disorder (ADHD) in adults has been revealed as 2.5%, it is evident that young people afflicted with ADHD who are under treatment by specialist services and paediatric services need to be cared for beyond the age of 16 years due to the prolonged situation of ADHD symptoms(Sexton et al. 2012). It is of utmost importance to address the different needs of adolescents and adult patients; and this can be done with effective precision by local service configuration with regard to being defined in the specifications of commissioning services.
Patient-centric care is crucial in the management of ADHD patients because the views of the respective young individuals should be at the center of the treatment procedure(Sumner et al. 2009). That means the patient should participate throughout the course of his/her treatment options but it is not implicative of the fact that he/she is enabled to make free choice. The provision of professional guidance and counsel is pivotal here for the cause of empowerment of patient choice.
It has been observed and researched that the diagnostic rates of attention deficit hyperactivity disorder (ADHD) are comparatively lower in girls than boys due to the fact of their being less disruptive in nature. This often leads to ADHD children struggling at school activities alongside facing problematic situations which needs to be checked at the preliminary levelAaron et al. 2002). The girls with ADHD symptoms tend to face severe problems related to cognition and language; and this adds to the greater social problems in later phases of life. Engaging with other agencies is another course that needs to be sought after while dealing in the ADHD issue.
Schools are important in detecting the potential ADHD symptoms in children and therefore be enthusiastically responsible enough to make specific recommendations for referral. The care giving services must be in close alignment with the justice system and the teams prioritizing youth offending for the overall welfare of the patients. As with revelation of research studies, it is observed that some subgroups of people with ADHD symptoms are comparatively at an increased criminality risk and the risk of substance abuse is also quite common(Dulcan, 1997).This is to be recommended that there is an immediate need for integrating the ADHD services and close involvement of commissioning teams.
When it comes to ADHD diagnosis rates in the United Kingdom, it can be mentioned that many instances are there where individuals with ADHD are yet to receive a diagnosis or treatment so far since their childhood or adolescence period(DuPaul et al. 2001). Recent studies have further revealed that despite significant increases in the recognition over the past two decades, attention deficit hyperactivity disorder (ADHD) is strangely enough under-diagnosed in Scotland. Diagnosis and treatment rates are invariably low in even the most densely populated regions, throughout the UK.
As a mere consequence, it is very likely that the diagnosed and already treated individuals are those with severity of disorder and symptoms likewise. Therefore, they belong to the groups that most likely require continuing services, not to mention the greatest ever support during the course of transition. Researchers have found that transition is generally not well managed in the services mostly and the problems of transition wreak havoc afterwards as per the clinical experience of the healthcare professionals(Munir et al. 1987). As the varying needs of the young adults are different from each other and simultaneously deserve to be treated by respective adult-oriented services, it can be said that there are gaps in clinical practice and much talked about services.
In order to cater to the challenges and fill in the gaps present in the existent service line, there should be proper set up of transition services. As per National Institute for Health and Care Excellence (NICE) recommendations, there is an urgent need for a planned transfer to an appropriate adult service in case the young individual continues having ADHD disorder symptoms or other sorts of treatment-needing co-existent conditions. Moreover, the transition needs proper planning in advance by both the referring services and receiving parties(Wilens et al. 2002). The process of transition between teams should be made a gradual process for instance lasting a minimum of 6-8 months or so. To render the transition process smoothly, commissioners, paediatric services, adult mental health services (AMHS), primary care services need to develop clear transition protocols for the cause of facilitating transition alongside ensuring maintenance of appropriate care standards.
Pre-transitional assessment is necessary too because the young adolescents should be re-evaluated at their respective school-leaving age with regard to being informed about the assessment result and required transitional need. The transition period must experience a joint transition appointment of both child and adult services in terms of ensuring the fact of meeting the varying needs of the young individual with ADHD appropriately(American Psychiatric Association, 1994). Much like pre-transition, post-transition phase needs to be inclusive of a comprehensive assessment by the receiving service alongside making provisions for reassessment of comorbid conditions. Last but not the least, shared-care arrangements must be there between primary and secondary care services in consideration of the prescription and monitoring of medications meant for ADHD – which need to be continued into the adulthood of the young adolescent individuals(Porter, 1997).
It can be mentioned in the concluding segment that setting up appropriate educational system, systems of management alongside promoting religiousness as well as enthusiasm will be inducive for the nurses and the caregiversin providing holistic care to the patients. Moreover, the caregivers can improve their respective quality of their caring services. The integration of ADHD services and the commissioning teams is integral to ensure effective management of ADHD patients, both children and young adults. General practitioners would be involved in the commissioning services with adequate knowledge, alongside the primary care givers. The transition services would be appropriate and continuous to follow up with the young patients in their respective adulthood. With new working arrangements being set up in NHS and NICE, it seems ADHD services would be improved and the improved infrastructure would be readily inclusive of referring patients into care pathways for serving the cause of specialist assessment. The cost of ADHD treatment is expensive both on an individual level or social level, and therefore ignoring the need for prioritization of ADHD services will never be an option ever
Aaron, P. G., Joshi, R. M., Palmer, H., Smith, N., and Kirby, E. (2002).Separating genuine cases of reading disability from reading deficits caused by predominantly inattentive ADHD behavior.J. Learn. Disabil. 35, 425–436.
Accardo, P.J., Blondis, T.A., Whitman, B.Y. and Stein, M. (Eds.) (2000). Attention-deficit disorders and hyperactivity in children and adults (2nd ed.). New York: Marcel Dekker, Inc.
American Academy of Pediatrics. (2001). Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics, 108, 1033-44.
American Psychiatric Association.(1994). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association.
Arnold, L.E. (2002). Treatment Alternatives for Attention-Deficit/Hyperactivity Disorder. In P.J. Jensen, & J. Cooper (Eds.), Attention-Deficit/Hyperactivity Disorder: State of the Science and Best Practices. Kingston, NJ: Civic Research Institute.
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