Pediatric ADHD Update

Transcription

1 Pediatric ADHD Update Carl T. Ratliff, Jr., D.O. Board Certified Adult Psychiatrist Child & Adolescent Psychiatrist Community Howard Regional Health Kokomo, Indiana

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3 Needs Assessment Identify symptom criteria for ADHD according to DSM V State the major rule out diagnoses Identify the primary comorbidities Choose between various treatment options based upon risk/benefit profiles.

4 Questions A mom brought her 8 y/o daughter c/o of her poor attention at home, not completing her homework, not listening to her teachers, and having poor grades. Upon evaluation, she is distractible and fidgety. Which of the following pieces of information will be the most important in establishing the diagnosis of ADHD? A. Poor attention to teachers and poor academics B. The presence of symptoms at school and at home C. Being inattentive and not responding to directions D. The child s high level of activity and distractibility in the office E. The presence of poor frustration tolerance

5 Questions The first symptoms of ADHD to remit in early adulthood is usually which of the following? A. Hyperactivity B. Distractibility C. Learning difficulties D. Impulse-control problems E. Decreased attention span

6 ADHD: Impacts Most researched topic in child psychiatry Affects about 5% of school-aged children Often a chronic condition into adulthood with only a partial remission of symptoms Psychiatric comorbidities are common Risk factor for several psychiatric disorders Pathway risk: Can lead to SUD, ODD and Conduct Disorder, Anti Social PD, lower academic and life attainment.

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8 Diagnosis Pattern of inattention and/or hyperactivityimpulsivity lasting at least 6 months Several symptoms must be present before age 7 ( DSM-IV) or age 12 ( DSM-V) Several symptoms must be present in at least two settings ( e.g., school, work, home) Symptoms interfere with or reduce quality of social, academic, or occupational functioning. Not better explained by oppositional or defiant behavior, or failure to understand

9 Inattention Symptoms Often fails to give close attention to detail or makes careless mistakes Often has difficulties sustaining attention Often does not seem to listen Often has difficulties in organizing tasks or activities Often avoids or dislikes tasks that require sustain mental effort ( e.g., homework) Often does not follow through with instructions and fails to finish work or chores Often loses needed things ( e.g., books, tools, keys) Often forgetful in daily activities Often easily distracted by extraneous stimuli

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11 Hyperactivity-Impulsivity Symptoms Often fidgets with hands or feet Often leaves seat when being seated is expected Often runs or climbs excessively ( or feels restless in adolescents or adults) Often has difficulty playing or engaging in leisure activities quietly Often on the go as if driven by a motor Often talks excessively Often blurts outs answers Often has difficulty waiting their turn Often interrupts or intrudes on others.

12 Diagnostic Specifiers Presentation types o Predominately inattentive presentation o Predominately hyperactive/impulsive o Combined presentation Severity o Mild o Moderate o Severe In partial remission o When fewer than full criteria met in last 6 months and impairment is still present

13 Features Prevalence o Pre-school children: 2%-5% o School age: 3%-8% o Adolescents & young adults: 4.4% o In outpatient mental health: 10%-15% o Among special education population: 44% M:F ratio: 3:1 o Lower prevalence in females and underdiagnosed Course o ADHD combined type younger onset o Hyperactivity gets less prominent as child grows older, and is the first symptoms to remit o 56% need tutoring and 30% repeat a grade

14 Differential Diagnosis Subsyndromal ADHD o Disruptive behavior disorder NOS ( DSM IV) o Other specified or unspecified ADHD ( DSM V) Bipolar Disorder Anxiety Disorder Intellectual Disability, Autism Spectrum Disorder, Learning Disorders. Medical & metabolic conditions o Hyperglycemia, anemia, lead poisonings, Lyme disease, thyroid disease. Congenital disorders o Fragile X syndrome, Cornelia de Lange syndrome, Fetal Alcohol Syndrome, Tourette s Disorder

15 ADHD vs. Bipolar Disorder In Bipolar Disorder o Activity more goal directed o Greater belligerence and irritability may be present o More grandiosity and racing thoughts o Less need for sleep, and more rested after sleep o Family history of bipolar disorder/mood disorder o Episodic symptoms o Types of mood/behavior related to depression vs. mania In ADHD o Fewer affective storms o Chronic rather than episodic Disruptive Mood Dysregulation Disorder ( DSM V)

16 Comorbidities Oppositional defiant disorder: 45%-65% Learning disorder: 20%-40% Anxiety disorder: 10%-30% Bipolar disorder, in older adolescents: 16%- 23% Conduct disorder: 8%-25% Tic disorder: 8%-34% Depressive disorder: 10%-18%

17 ADHD: Tourette's and Autism Spectrum Comorbidities Tourette's disorder o Up to 50% have ADHD o Involvement of noradrenergic circuits projecting from locus coeruleus to frontal lobes in both Autism spectrum disorder o DSM-IV: excludes diagnosis of both o DSM V: permits diagnosis of both o 14%-45%: symptoms of inattention, hyperactivity and/or impulsivity.

18 Prognosis ADHD is chronic and course is variable o Hyperactivity is the first symptoms to remit o Distractibility is the last symptoms to remit o Pathway is a risk factor to multiple like problems Remission rates o Remission is unlikely before age 12 o 70%-85% will continue into adolescence o 50%-60% continue to display ADHD symptoms into adulthood.

19 ADHD as a risk factor Treatment s protective against substance use o Children with ADHD not treated with stimulants have higher risk of substance abuse than those treated. Anti-social behavior: 25%-45% Smoking or substance use disorder: 15%-19%

20 ADHD as a risk factor Higher rate of the following: o Motor vehicle accidents o Injury and higher medical expenses o Earlier sexual activity and teen pregnancy o Lower academic attainment, higher rates of suspension and dropping out o Occupational, social, marital, and parenting problems o Increased crime rate

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22 Neurobiology Question: Neuroimaging in ADHD has revealed which of the following? A. Reduced metabolism in the prefrontal cortex B. Increased blood flow in the left temporal lobe C. Increased total brain volume on MRI D. Increased size of the caudate nucleus E. Decreased size of the parietal and occipital cortex

23 ADHD Genetic Neuroanatomic CNS Insult Neurochemical Environmental

24 Molecular Genetics Heritability in monozygotic twin studies o Hyperactivity: 67%-77% concordance o Inattention: 76%-98% concordance Several genes involved with cumulative effects o Dopamine receptor D4 gene ( DRD4): Chr. 11 o Dopamine transporter gene ( DAT1): Chr. 5 o Dopamine-beta-hydroxylase gene ( DBH): Chr.9

25 Prefrontal Deficits ADHD: dysregulation of prefrontal cortex and its connections to striatum and cerebellum o Leads to distractibility, forgetfulness, impulsivity, poor planning, and motoric hyperactivity Neurochemical effects: Norepinephrine increases the signal Dopamine decreased the noise Meds: stimulate a2 and D1 receptors

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27 Associated features o Impaired working memory, motor sequencing, sense of time o Delay in posterior to anterior cortical maturation o Early treatment with stimulants may reverse some of the neurobiochemical changes in a growing brain.

28 Neuroimaging findings Smaller total cerebral volumes Smaller frontal lobe volumes Smaller caudate volumes Smaller cerebellar volumes Smaller corpus callosal volumes ( splenium) Lower prefrontal perfusion/metabolism Lower levels of dopamine transporter in the nucleus accumbens ( reward center) EEG: increased slow wave activity in the right prefrontal area.

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30 CNS Insults Pregnancy and delivery complications Prenatal exposure to alcohol, cocaine, cigarette Low birth weight Toxemia in pregnancy Perinatal trauma & traumatic brain injury Heavy metal poisoning ( lead) Exposure to organophosphate herbicides Soft neurological signs are found more often in children with ADHD

31 Assessment and Treatment Question: An 8 y/o diagnosed with severe ADHD is finally stabilized on stimulant medication but develops tics. Patient was referred to Child Psychiatrist cause his parents do not want him to continue stimulant medication. What is your most likely response?

32 Questions A. Advise trying behavioral therapy alone and stop stimulant medication B. Educate about other options. Tics are not absolute contraindications and may be present with ADHD C. Initiate bupropion and stop stimulant medication immediately D. Recommend neuro/bio-feedback as first line option E. Recommend CBT with Clonidine as first line option

33 Question: Which of the following is the evidence based approach to treating ADHD with Bipolar disorder? A. Begin stimulant and mood stabilizer at the same time B. Use of stimulant medications is an absolute contraindication C. Stabilize bipolar symptoms first followed by addition of stimulant medication if needed D. Use of bupropion to treat bipolar disorder & ADHD E. Use guanfacine to treat bipolar disorder & ADHD

34 Foundational Assessments Psychiatric assessments o History, psychiatric, medical, developmental, family Medical assessments o Physical: height, weight, hearing, vision, stigmata ( Fragile X, FAS) o Labs: consider lead

35 Foundational Assessments ADHD rating scales o Vanderbilt Assessment Scales o Inattention/Over activity with Aggression ( IOWA) o Achenbach Child Behavior Checklist o Connors ADHD Rating Scales Attention tests o Connors Continuous Performance Test o Test of Variable Attention

36 Computerized ADHD Testing T.O.V.A ( Test of Variables of Attention) o In the T.O.V.A., a little box appears within a bigger box. When the little is at the top, the patient clicks a mouse. Connors CPT ( Connors Continuous Performance Test) o The Connors s CPT flashes letters randomly on the screen and the task is to tap the spacebar for every letter except for X Both tests: a game requiring vigilance o Presented on a computer screen o Used prior to treatment and intermittently to track response to treatment

37 Additional Assessments Achievement test o Quality of what they have learned o Wechsler Individual Achievement Test o Peabody Individual Achievement Test IQ Test Exclude possibility of lower IQ o Wechsler Intelligence Scale for Children aged 6-16 o Wechsler Preschool & Primary Scale of Intelligence, ages 2 ½-7 Neuroimaging o Only if neurologic history or signs present

38 Treatment & Management Stimulant Medication Non-stimulants Individual Therapy CBT, Social Skills Training Behavioral Mod Behavioral Parent Training & Behavioral Classroom Mgt Other Self-help Parent Mgt

39 Treatment: MTA Study Multi-modal treatment of ADHD study NIMH funded 14 months of treatment Four arms of treatment o Medication treatment o Behavioral treatment o Combined treatment o Community care

40 MTA Outcomes Combined treatment and medication treatment alone were both significantly superior to behavioral treatment alone and to community care in reducing core ADHD symptoms Combined treatment did not yield significant greater benefits than medication treatment for core ADHD symptoms Only combined treatment was consistently superior to routine community care in other areas of functioning o Anxiety symptoms o Academic performance o Oppositional behavior o Social sills

41 Psychosocial Therapy Evidence-Based treatment o Behavior therapy: teacher & parents are trained and they implement the behavior modification Behavioral Parent Training ( BPT) Behavioral Classroom Management ( BCM) Other Treatments Cognitive therapy: not effective in children, possibly effective in adolescents Social skills training: ineffective Neuro/bio-feedback is an open but not first line

42 Behavioral Parent Training & Classroom Management Use time-outs effectively ( loss of privileges) Manage non-compliant public behavior Use of a daily school report card Anticipate future misbehavior Parents should be treated for own psychopathology Classroom management: positive reinforcement: immediate rewards for positive behavior

43 Self Management Training Older adolescents: self monitor behavior Record behavior Evaluate success Self reinforce through rewards Follow academic productivity and accuracy guidelines and set timely goals Improve communications Children w ADHD classified under IDEA as having a SED ( Serious Emotional Disturbance) or other impairment.

44 School Programs 504 plans 504 Plan is an individually designed plan that includes a list of accommodations Preferential seating Reduced homework load Extra supervision Selection of appropriate group partners Verbal and visual cues Help with organized skills ( daily report cards)

45 General Medication Algorithms ADHD without comorbidities ADHD with Tics ADHD with Anxiety or Depression ADHD with Substance Abuse Disorder ADHD with Bipolar Disorder Use in Intellectual Disabilities ( aka MR) and Autism

46 ADHD without comorbidities Stage 0: Diagnosis and family consult Stage 1: Methylphenidate/Amphetamine Stage 2 Stimulant not use in Stage 1 o Atomoxetine, also considered Stage 1 Stage 3: Other Non stimulant medications Stage 4: Bupropion or TCA Stage 5: Agent not used in Stage 4 Stage 6: a2 agonist ( clonidine/guanfacine)

47 Atomoxetine: when 1 st line? Stimulant are more effective o Atomoxetine effect size: 0.62 o Stimulant effect size 0.91 ( immediate release) 0.95 ( long-acting) Atomoxetine first line ADHD with: o Substance use disorder o Anxiety disorder o Tics

48 ADHD Meds with Tics Stimulant medication may be used to effectively treat ADHD with Tic disorder o No absolute contraindication Start ADHD algorithm. If improvement in ADHD but not in Tics. o Change to non-stimulant medication o Add a2 agonist ( clonidine/guanfacine) o Add antipsychotic: second or first generation antipsychotic ( Pimozide FDA indicated for treatment-resistant tic disorder)

49 ADHD comorbid anxiety/depression Anxiety o Start ADHD algorithm o If anxiety remains, add SSRI o Atomoxetine may be considered first line Depression If depression more severe than ADHD, start treatment for depression first If ADHD is more severe than depression, start treatment for ADHD along with monitoring and treating depression

50 ADHD with Aggression Start ADHD algorithm If improvement in ADHD but not in aggression, to the stimulant add o Behavioral Intervention o Atypical Antipsychotic o Lithium or Valproate

51 Treatment in presence of other comorbidities Substance Use Disorder o Stabilize sobriety prior to start of stimulant o Prescribe a long acting stimulant formulation Bipolar Disorder o Mood stabilizer first Intellectual Disability and Autism o Frequently comorbid with ADHD o ADHD medication still effective but patient tend to be more sensitive to SE. Start at lower doses.

52 Stimulants What is the most common side effect of stimulant medications? A. Sleep disturbances B. Poor appetite C. Headache D. Tics E. Irritability and restlessness

53 Stimulant Overview Stimulant efficacy o 75% of children benefit o 90% response after two medication trials Side Effects: Loss of appetite, poor sleep, HA, dyspepsia, tics, low growth rate, exacerbation of psychosis, and rebound phenomenon. Discontinuation o Can be tapered without significant withdrawal o Rebound possible in higher doses.

54 Differences in stimulants Methylphenidate o Blocks reuptake of norepinephrine & dopamine o FDA approved use for age 6 years and older Amphetamines o Block reuptake plus direct release of norepinephrine & dopamine o FDA approved use for age 3 years and older Immediate release form of both o Shorter acting, minimizes insomnia Extended release forms of both o Minimizes high, jitteriness, dyspepsia, on/off

55 Short Acting Meds Amphetamine o Dextroamphetamine ( Dexedrine) o Mixed dextroamphetamine and amphetamine salts ( Adderall)

56 Short Acting Meds Methylphenidate o Methylphenidate ( Ritalin) o Methylphenidate chewable tabs ( Methylin) o Methylphenidate oral solution ( Methylin oral suspension) Dexmethylphenidate ( Focalin) Non stimulant medications o Bupropion

57 Long Acting Medications Amphetamine o Mixed dextroamphetamine/amphetamine salts ( Adderall XR) o Amphetamine ER/extended release oral suspension ( Dyanavel XR) o Amphetamine ER/extended release orally disintegrating tablets ( Adzenys XR-ODT) o Dextroamphetamine SR ( Dexedrine spansule) o Lisdexamphetamine ( Vyvanse)

58 Long Acting Stimulants Methylphenidates Methylphenidate ER ( Metadate ER) Methylphenidate ER chewable tablets ( Quillichew ER) Methylphenidate LA ( Ritalin LA) Methylphenidate CD ( Metadate CD) Methylphenidate ER ( Concerta) Methyphendiate XR ( Aptensio XR) Methylphenidate XR oral suspension ( Quillivant XR) Methylphenidate patch ( Daytrana)

59 Long acting Stimulants Dexmethylphenidate XR ( Focalin XR)

60 Non Stimulants Selective norepinephrine reuptake inhibitor o Atomoxetine ( Strattera) Alpha-2 adrenergic agonists o Guanfacine ( Tenex) o Guanfacine extended release ( Intuniv) o Clonidine extended release ( Kapvay)

61 Side Effects Growth: Effects on growth is small to none o Med holidays lead to growth rebound GI: anorexia & GI disturbances o Common, may result in weight loss o Severe hepatic injury has occurred Sleep: Insomnia & parasomnias Mood & Psychosis o May exacerbate existing or trigger newly emergent mania or psychosis Anxiety & agitation o May exacerbate anxiety, tension agitation, aggression

62 Side Effects Tics : May increase tics Pregnancy ( Pregnancy category C) o High doses of amphetamines have embryo toxic and teratogenic potentials. CNS o May lower seizure threshold o Restlessness and dizziness Starting/discontinuing medications o Avoid within 2 weeks of MAOI use o Rebound of ADHD symptoms may occur with abrupt withdrawal. Cardiac: may increase HR and BP.

63 Stimulants and Cardiac Risk Increased risk of sudden cardiac death in children & teens 564 persons ( ages 7-19) who died from sudden death compared to 564 who died as passengers in MVAs ( control group) o 10/564 in sudden death group took stimulants o 2/564 in MVA control group took stimulants o Significant association founds between sudden death and stimulant use ( odds ratio = 7.4) FDA recommendation For all: obtain cardiac history, perform physical exam For suspected patient: obtain EKG or echocardiogram. AJP, Gould et al, 2009

64 Methylphenidate-Immediate Release Methylphenidates: Methylin, Ritalin D-isomer of methylphenidate ( Focalin) Age 6 and over: start 5mg BID; increase 5-10mg q week until response o Doses over 60mg qd not recommended o Used with caution in patients with prior history of seizures or EEG abnormalities, blurred vision, and difficulties of vision ( glaucoma)

65 Methylphenidate- Extended Release ( Concerta) Duration of effects: hrs Should not be crushed or chewed Osmotic pump delivery system ( OROS) GI disturbances and shadow capsule in stool Max FDA approved dose o mg/day o < 13 54mg/day

66 Methylphenidate XR ( Aptensio XR) 10, 15, 20, 30, 40, 50, 60 mg capsules 40% immediate release and 60% controlled release for up to 12 hrs. Capsules may be swallowed whole or opened and contents sprinkled over a spoonful of cold applesauce and swallowed. Do not crush or chew. Initial dose 10mg Dose advancement: increments of 10mg every 7 days Max Dose: 60mg

67 Methylphenidate Long Acting ( Metadate CD & Ritalin LA) Beaded delivery system: can be opened and sprinkled capsules Duration of effect 8-9 hrs Second peak effect around 4 hrs Ritalin LA delivers less medication during the second half of release

68 Methylphenidate ER chewable tablets ( Quillichew ER) Continuous release over 6 to 8 hrs with a duration of action up to 13 hrs. 20mg, 30mg, 40mg ( not scored) Initial dose: 20mg Dose advancement: Increments of 10mg, 15mg, or 20mg per day every 7 days Max dose: 60mg

69 Mixed Amphetamine Salts ( Adderall) Short- and long-acting forms: Adderall and Adderall XR Long-acting form has a beaded delivery system with flexible dosing options Adderall XR: FDA alert in 2005 after sales suspended in Canada because of concerns of sudden death with heart conditions Benefits of mixed amphetamine salts o Combination of amphetamine and dextroamphetamine provided a graded onset and duration of action with smoother delivery

70 Amphetamine ER extended release oral suspension 2.5mg amphetamine as base per ml ( Dyanavel XR) Combination of immediate and extended release for a duration of action up to 13 hrs. Initial dose: 2.5 or 5 mg Dose advancement: Increments of 2.5 to 10mg per day every day 4 to 7 days Max dose: 20mg

71 Amphetamine ER- extended release orally disintegrating tablets ( Adzenys XR-ODT) Combination of 50% immediate and 50% extended release: levels are comparable to amphetamine-dextroamphetamine ER mixed salts capsules when equivalent doses are used Initial dose: 6.3 Dose advancement: 3.1 or 6.3 mg per day every 7 days Max dose: o 6-12 years: 18.8mg o 13 years: 12.5mg

72 Lisdexamfetamine Dimesylate ( Vyvanse) First prodrug stimulant medication For consistent release for longer period of time with less potential for abuse Side effects the same as for amphetamines, including poor appetite, poor sleep, tics, and mood swings Black box warning of sudden death and serious cardiovascular adverse events, like other amphetamines.

73 Non Stimulants Selective Norepinephrine reuptake inhibitor o Atomoxetine ( Strattera) o At least 10 to 12 hours o 0.5mg/kg per day for a minimum of 3 days o Dose advancement increase to 1.2mg/kg after a minimum of 3 days ( max 100mg per day) o FDA black box warning for suicide ( 0.4%) o Liver damage, reported as idiosyncratic reaction

74 Alpha 2 adrenergic agonists Guanfacine Extended release ( Intuniv) o At least 10 to 12 hrs o 1mg per day o Increments of 1mg per day at no less than weekly intervals o Max dose: o 12 years: 4 mg o >12 years: 7 mg

75 Alpha 2 adrenergic agonists Clonidine extended release o Kapvay o At least 10 to 12 hrs o 0.1 mg at bedtime on days 1 through 7 o Increments of 0.1 mg per day at no less than weekly intervals. For titrations, divide the dose twice daily, either equally or higher dose before bedtime o Max dose: 0.4 mg per day

76 The End Questions?

77 References A meta-analysis of behavioral treatments for attentiondeficit/hyperactivity disorder.fabiano GA, Pelham WE Jr, Coles EK, Gnagy EM, Chronis-Tuscano A, O'Connor BC Clin Psychol Rev Mar;29(2): Epub 2008 Nov 11. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Sonuga-Barke EJ, Brandeis D, Cortese S, Daley D, Ferrin M, Holtmann M, Stevenson J, Danckaerts M, van der Oord S, Döpfner M, Dittmann RW, Simonoff E, Zuddas A, Banaschewski T, Buitelaar J, Coghill D, Hollis C, Konofal E, Lecendreux M, Wong IC, Sergeant J, European ADHD Guidelines Group Am J Psychiatry. 2013;170(3):275. Comprehensive Review of CAP Initial Certification Edition v5.1 Krasuski J. American Physician Institute

78 References Cont. American Psychiatric Association. Attention-deficit/hyperactivity disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA p.59. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser S, Pediatrics. 2011;128(5):1007. Practice parameter for the assessment and treatment of children and adolescents with attentiondeficit/hyperactivity disorder. Pliszka S, AACAP Work Group on Quality Issues, J Am Acad Child Adolesc Psychiatry. 2007;46(7):894. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, Wolraich M, Brown L, Brown RT, DuPaul G, Earls M, Feldman HM, Ganiats TG, Kaplanek B, Meyer B, Perrin J, Pierce K, Reiff M, Stein MT, Visser SPediatrics. 2011;128(5):1007. Integrated pharmacologic treatment of attention-deficit hyperactivity disorder (ADHD). Horst RO, Hendren RLEssent Psychopharmacol. 2005;6(5):250. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. Goldman LS, Genel M, Bezman RJ, Slanetz PJ, JAMA. 1998;279(14):1100. Rating scales in attention-deficit/hyperactivity disorder: use in assessment and treatment monitoring. Conners CK J Clin Psychiatry. 1998;59 Suppl 7:24. Practice parameters for the assessment and treatment of children, adolescents, and adults with attentiondeficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. Dulcan M, J Am Acad Child Adolesc Psychiatry. 1997;36(10 Suppl):85S.

79 References Cont. Integrated pharmacologic treatment of attention-deficit hyperactivity disorder (ADHD). Horst RO, Hendren RLEssent Psychopharmacol. 2005;6(5):250. Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Council on Scientific Affairs, American Medical Association. Goldman LS, Genel M, Bezman RJ, Slanetz PJ, JAMA. 1998;279(14):1100. Rating scales in attention-deficit/hyperactivity disorder: use in assessment and treatment monitoring. Conners CK J Clin Psychiatry. 1998;59 Suppl 7:24. Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. Dulcan M, J Am Acad Child Adolesc Psychiatry. 1997;36(10 Suppl):85S.