Updated European Consensus Statement on Diagnosis and Treatment of Adult ADHD

Attached is an important update of the European Consensus statement regarding the diagnosis and treatment of adult ADHD. This is yet another important resource that includes several APSARD members as authors.

CLICK HERE TO VIEW THE FULL PAPER.

Abstract
Background Attention-deficit/hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that often persists into adulthood and old age. Yet ADHD is currently underdiagnosed and undertreated in many European countries, leading to chronicity of symptoms and impairment, due to lack of, or ineffective treatment, and higher costs of illness.

Methods The European Network Adult ADHD and the Section for Neurodevelopmental Disorders Across the Lifespan (NDAL) of the European Psychiatric Association (EPA), aim to increase awareness and knowledge of adult ADHD in and outside Europe. This Updated European Consensus Statement aims to support clinicians with research evidence and clinical experience from 63 experts of European and other countries in which ADHD in adults is recognized and treated.

Results Besides reviewing the latest research on prevalence, persistence, genetics and neurobiology of ADHD, three major questions are addressed: (1) What is the clinical picture of ADHD in adults? (2) How should ADHD be properly diagnosed in adults? (3) How should adult ADHDbe effectively treated?

Conclusions ADHD often presents as a lifelong impairing condition. The stigma surrounding ADHD, mainly due to lack of knowledge, increases the suffering of patients. Education on the lifespan perspective, diagnostic assessment, and treatment of ADHD must increase for students of general and mental health, and for psychiatry professionals. Instruments for screening and diagnosis of ADHD in adults are available, as are effective evidence-based treatments for ADHD and its negative outcomes. More research is needed on gender differences, and in older adults with ADHD.

ADHD Likely Reduces Estimated Life Expectancy by Young Adulthood

Russell A. Barkley, Ph.D.

Nearly 15 years ago, suggestive evidence began to arise that ADHD may have a detrimental impact on life expectancy. Such opinions were based on what were then new findings from a longitudinal study at Stanford university initiated by Terman of gifted children followed their entire lifespan. The findings by Friedman and colleagues (2002) indicated that even among this gifted sample, children who placed below the bottom 25th percentile of the population in the personality trait known as Conscientiousness had a 7-8 year reduction in their lifespan compared to the remainder of their sample. Conscientiousness refers to the use of one’s conscience in making decisions about one’s actions and their consequences for one’s self and others that contribute to the individual’s longer term welfare. When low, Conscientiousness acts to reduce life expectancy due to its being a background trait that predisposes people to engage in adverse health and lifestyle activities that are known to reduce life expectancy, such as smoking, alcohol and drug use, risk taking, poor health maintenance activities, poor diet, etc. Indeed, low Conscientiousness has been repeatedly shown to mediate the risk of earlier death by all causes (Bogg & Roberts, 2004). The trait is negatively related to self-regulation generally and behavioral disinhibition specifically. Naturally, then, it is also negatively related to ADHD that includes disinhibition as one of its central symptom dimensions. Hence, if those in the bottom quartile on this trait had a significant reduction in lifespan, even among gifted children, those with ADHD would be expected to have an even greater reduction in life expectancy as those with ADHD place in the bottom 5-7 percent of the population in their poor inhibition.

Besides being low in Conscientiousness, there are a number of other reasons to expect that ADHD would be linked to a reduced life expectancy by young adulthood. For one thing, ADHD is linked to increased adverse consequences in nearly every major domain of life activity studied to date (Barkley et al., 2008), some of which are linked to shortened life expectancy. For instance, ADHD is associated with higher risks for accidental and self-inflicted injuries in childhood and adulthood (Nigg, 2013). Adverse driving outcomes, including more vehicular crashes (Barkley, 2015c; Barkley & Cox, 2007), are also associated with ADHD. ADHD is also associated with an increased risk for suicidal ideation, attempts, and completions (Barbaresi et al., 2013; Barkley et al., 2008). And teens and adults with ADHD-C are far more likely to be involved in interpersonal hostility generally and antisocial activities specifically that include violent crimes, reactive aggression, and intimate partner violence even when conduct disorder is not present or is statistically controlled (Buitelaar, Posthumus, & Buitelaar, 2015; Mohr-Jensen & Steinhausen, 2016; Saylor & Amann, 2016). All of these variables would predispose to an increased risk for greater morbidity and likely earlier mortality by violent means.

For another, ADHD is associated with various adverse medical conditions, including increased rates of seizures, obesity, eating pathology, traumatic brain injury, tobacco, alcohol, and marijuana use, dental trauma and caries, sedentary behavior or low rates of exercise, sleeping problems, migraines, and risk for future coronary heart disease, as well as decreased involvement in preventive health, nutrition, and dental hygiene activities (Barkley, et al., 2008; Barkley, 2015b; Nigg, 2013). Many of these conditions are well-known correlates of reduced life expectancy and are used in algorithms that predict life expectancy as occurs in public health research and in the life insurance industry.

Over the past decade, a few studies have specifically examined the issue of greater mortality in ADHD using large epidemiological samples or even entire populations. They showed that in childhood, the mortality risk is nearly doubled that of the typical comparable population, and in adulthood, that risk is more than quadrupled (Dalsgaard, Ostergaard, Leckman, Mortensen, & Pedersen, 2015; Jokela, Ferrie, & Kivimaki, 2009; London & Landes, 2016). This risk of earlier mortality by midlife seems to be largely a result of a greater proneness to accidental injury but also, to a lesser extent, from an elevated risk for suicide (Barbaresi et al., 2013; Dalsgaard et al., 2015). These studies do not address, however, the cumulative risk of chronically engaging in adverse health and lifestyle activities that can reduce life expectancy after mid-life. Thus, Mariellen Fischer, Ph.D. and I decided to use our Milwaukee longitudinal study to examine the possibility of reduced life expectancy in our ADHD and control children at their young adult follow-up (mean age 27 years) by entering 14 variables related to disability, health, and lifestyle into a recently available estimated life expectancy (ELE) calculator provided by the University of Connecticut Goldenson Center for Actuarial Research. We presented our initial pilot findings at the APSARD meeting in January of 2018 that suggested just such a significant impact on life expectancy. We then proceeded to undertake a more complete analysis of our data the results of which will soon be published in APSARD’s affiliated journal, The Journal of Attention Disorders. (Barkley & Fischer, in press).

Our study found that cases having hyperactive child syndrome, or ADHD-C, in childhood manifested a 9.6 year reduction in estimated healthy life expectancy in remaining years, a 1.2 year period of greater unhealthy life expectancy in remaining years, and an overall 8.4 year reduction in total life expectancy than did control children by young adulthood. Moreover, the persistence of ADHD to adult follow-up was associated with an even worse impact on these ELE measures, with a 12.7-year reduction in healthy life expectancy and an 11.1-year reduction in total ELE than was seen in control cases. Persistent cases had a 5.3-year reduction in healthy life expectancy and a 4.6-year reduction in total ELE than nonpersistent ADHD-C cases. And both persistent and nonpersistent ADHD cases had significantly lower ELEs by adulthood than did control cases. This is the first study to compute estimated remaining years of life expectancy by adulthood in children with ADHD-C and to compare persistent and nonpersistent ADHD cases on these ELE parameters.

The magnitude of such reductions in life expectancy can be appreciated by understanding that such reductions are far greater than those associated with smoking, obesity, alcohol use, high cholesterol, and high blood pressure either individually or combined! Why? Because ADHD has been found to predispose individuals to engage in a number of such adverse health and lifestyle activities. For instance, we noted that the disorder reduced ELE in our study through its association with 8 of the 14 variables entered in the ELE calculations. These included the demographic factors of reduced education, lack of high school graduation, and lower annual income in the ADHD-C groups but also in the health and lifestyle factors of greater alcohol consumption, poorer overall health, reduced sleep, increased likelihood of smoking and of smoking more than 20+ cigarettes per day, and possibly greater adverse driving consequences resulting in license suspensions and revocations. Beyond these first order or more proximal factors that were adversely affecting life expectancy, we showed that the background trait of behavioral disinhibition explained more than 30% of the variance in life expectancy in our samples, consistent with the findings noted above concerning the role of low Conscientiousness in reducing lifespan.

These findings in the context of the other research on increased mortality by mid-life due to risk of accidental injuries and suicide argue for ADHD being viewed as a public health and not just a mental health disorder. They should also give impetus to efforts to try to reduce those first order factors that are predisposing to reduced life expectancy, such as obesity, smoking, excess alcohol use, poor diet, poor sleep, limited exercise, etc. in children and adults with ADHD. After all, estimated life expectancy is malleable – change the adverse health and lifestyle factors affecting it and one can improve quality of life as well as life expectancy. But our results also suggest that without efforts to address the background trait of poor inhibition specifically and ADHD symptoms more generally, trying to improve only those first order factors may have only limited success. Adding ADHD medications and evidence based psychosocial treatments to address the background traits predisposing those with ADHD to engage in these first order adverse activities is also likely to be necessary. Our findings also argue for making primary care physicians more aware of the linkage between ADHD, poor inhibition, and reduced life expectancy as they are the one’s most likely to be trying to improve the adverse health and lifestyle activities of individuals and yet are not screening for the significant role that ADHD may be playing in their failures to do so.

References

Barbaresi, W. J., Colligan, R. C., Weaver, A. L., Voigt, R. G., Killian, J. M., Katusic, S. K. (2013). Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: A prospective study. Pediatrics, 131, 637-644.
Barkley, R. A. (2015c). Health problems and related impairments in children and adults with ADHD. In R. A. Barkley (ed.) Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th Ed)(pp. 267-313). New York, NY: Guilford Press.
Barkley, R. A. & Cox, D. J. (2007). A review of driving risks and impairments associated with Attention-Deficit/Hyperactivity Disorder and the effects of stimulant medication on driving performance. Journal of Safety Research, 38, 113-128.
Barkley, R. A. & Fischer, M. (in press). Hyperactive child syndrome and estimated life expectancy at young adult follow-up: The role of ADHD persistence and other potential predictors. Journal of Attention Disorders. DOI: 10.1177/1087054718816164
Barkley, R. A., Murphy, K. R., & Fischer, M. (2008). ADHD in adults: What the science says. New York: Guilford Press.
Bogg, T. & Roberts, B. W. (2004). Conscientiousness and health-related behavior: A meta-analysis of the leading behavioral contributors to mortality. Psychological Bulletin, 130, 887-919.
Buitelaar, J. N. J., Posthumus, J. A., & Buitelaar, J. K. (2015). ADHD in childhood and/or adulthood as a risk factor for domestic violence or intimate partner violence: a systematic review. Journal of Attention Disorders. ePub ahead of print, doi: 10.1177/1087054715587099.
Dalsgaard, S., Ostergaard, S. D., Leckman, J. F., Mortensen, P. B., & Pedersen, M. G. (2015). Mortality in children, adolescents and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet, 385, 2190-2196.
Friedman, H. S., Tucker, J. S., Schwartz, J. E., Tomlinson-Keasey, C., Martin, L. R., Wingard, D. L., & Criqui, M. H. (1995). Psychosocial and behavioral predictors of longevity: The aging and death of the “Termites.” American Psychologist, 50, 69–78.
Jokela, M., Ferrie, J. E., & Kivimaki, M. (2008). Childhood problem behaviors and death by midlife: The British National Child Development Study. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 19-24.
London, A. S., & Landes, S. D. (2016). Attention deficit hyperactivity disorder and adult mortality. Preventive Medicine, 90, 8-10.
Mohr-Jensen, C., & Steinhausen, H. C. (2016). A meta-analysis and systematic review of the risks associated with childhood attention-deficit hyperactivity disorder on long-term outcome of arrests, convictions, and incarcerations. Clinical Psychology Review, 48, 32-42.
Nigg, J. T. (2013). Attention-deficit/hyperactivity disorder and adverse health outcomes. Clinical Psychology Review, 33, 215-228.
Saylor, K. E. & Amann, B. H. (2016). Impulsive aggression as a comorbidity of attention-deficit/hyperactivity disorder in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 26, 19-25.

9 Questions to Ask When You Suspect Your Preschooler May Have ADHD

Tanya Froehlich, M.D., M.S.
Associate Professor of Pediatrics
Cincinnati Children’s Hospital Medical Center

This post originally appeared on Cincinnati Children’s blog. (or copy and paste the link: http://blog.cincinnatichildrens.org/healthy-living/child-development-and-behavior/9-questions-suspect-preschooler-adhd/)

Typically, ADHD is diagnosed during the school years, particularly around age 7. But it is possible to diagnose it as early as four years old. However, it is a difficult diagnosis to make at this young age.

All preschoolers, by nature, are active, impulsive, oppositional and defiant, which are also descriptors of kids with ADHD (attention-deficit/hyperactivity disorder). Kids around this age are impatient, learning how to handle themselves, forgetful, and what we adults would call “careless.”

So how can parents tell if their child’s behavior is “typical,” or if there is an underlying neurodevelopmental issue like ADHD?

The answer is not clear-cut, and it’s much easier to identify hyperactivity in preschoolers than it is inattention. It is not developmentally appropriate to expect children this age to perform effort-filled tasks for extended periods of time. Asking yourself the below nine questions may help you differentiate between “typical” preschool behavior, ADHD, and some other conditions which can masquerade as ADHD.

9 QUESTIONS TO ASK WHEN YOU SUSPECT YOUR PRESCHOOLER MAY HAVE ADHD

1. HOW OFTEN ARE YOU GETTING CALLS FROM PRESCHOOL?
Are you getting calls about your child’s behavior a couple of times a month? Or is it multiple times a week? Typical preschoolers push boundaries and may get in trouble occasionally. However, preschoolers with ADHD are more disruptive and get into things they shouldn’t much more often than their peers. Preschool teachers are concerned because they frequently can’t sit in one place and have problems with impulse control.

2. HOW IS YOUR CHILD DOING WITH CIRCLE TIME?
Preschoolers with ADHD often have difficulty with circle time. The teacher isn’t reading directly to your child. Rather, he or she is interacting with the whole class. Because they’re not being spoken to directly, kids with ADHD get lost in these situations and their attention wanders. They do much better with one-on-one learning situations in which they get immediate feedback.

3. CAN YOUR CHILD FOLLOW ONE- OR TWO-STEP DIRECTIONS WITHOUT GETTING DISTRACTED?
Preschoolers should be able to follow one- and two-step directions, such as, “Hang up your coat and put your shoes away.” Sure, there are some “typical” preschoolers who won’t follow instructions because they’re feeling defiant. But kids with ADHD often have more problems with working memory than other children. They may want to do what you’ve asked, and may begin to attempt it, but get distracted by something else.

4. DOES YOUR CHILD “DART” AT THE STORE OR AT PRESCHOOL?
Kids with ADHD will frequently “dart.” They’re flight risks. They’re supposed to be in line at school, moving from class to recess, but go in another direction. This could be an indicator of your child’s distractibility and impulsivity.

5. DO YOU AVOID TAKING YOUR CHILD OUT IN PUBLIC, EVEN TO CASUAL, FAMILY-FRIENDLY PLACES?
Children with ADHD can’t sit still and will frequently run off and get into things. This can become so problematic that parents avoid taking them to family-friendly restaurants. Some refrain from short trips to the store because of the disastrous results.

6. HAS YOUR CHILD HAD HER HEARING CHECKED?
One ADHD symptom is “not seeming to listen when spoken to directly.” However, there can be many reasons why your child doesn’t seem to listen or has trouble following directions. One principle reason may be that your child has a hearing problem. This is why the AAP recommends that kids have their hearing checked as a part of a diagnostic evaluation.

7. DO YOU THINK YOUR CHILD UNDERSTANDS YOUR WORDS WHEN YOU SPEAK TO HIM?
Sometimes parents chalk up their child’s inability to follow through on directions as inattention or impulsivity, and therefore assume that the cause is ADHD. However, children with language or learning issues can show the same behaviors. They don’t follow through on instructions because they have difficulty comprehending them. Along these lines, kids may not sit still to listen to a story because they can’t understand it. As part of an evaluation, your doctor should consider whether a language or learning issue might be mimicking ADHD, or co-existing with ADHD. Children with this condition have higher rates of language and learning difficulties compared to the general population.

8. COULD YOUR CHILD HAVE ANOTHER HEALTH CONDITION, LIKE SLEEP APNEA?
We also need to rule out other potential health conditions that can affect a child’s behavior before considering ADHD. For example, sleep problems can mimic the condition because children who are not well-rested will not behave well, and are often hyper. Therefore, if your preschooler snores, which is not typical, it could be a sign of sleep apnea and you should report this to your doctor.

9. HAS YOUR CHILD UNDERGONE AN ACUTE STRESSOR?
If you’re seeing an acute behavioral problem on the heels of a big family stressor, I would wait it out – and get your child help for dealing with this stressor – before considering ADHD. For example, a recent death in the family, an illness, a parental separation, or a new baby can all impact a child’s behavior negatively. But this is still considered “normal.” Behavioral issues should be going on for six months or longer before we would consider ADHD as a possibility. Furthermore, if ADHD is the cause, the behavior problems will persist even after the child has recovered from the acute stressor.

PUTTING IT ALL TOGETHER
Adding to the complexity when trying to differentiate ADHD from typical preschool behavior is one hallmark of the condition: variability. The same child may behave well at certain times but not at others, so parents may wonder why the child can’t “get it together” more consistently. This likely has something to do with the fact that children with ADHD are often: More sensitive to environmental factors than other children; tend to do better in one-on-one situations; and act differently in the presence of an authority figure and when rewards or high-interest motivators are present. Despite this day-to-day or moment-to-moment variability in performance, children with condition show ADHD-related behaviors in more than one setting. Not just at home or just at school, but in both.

As you’re answering the above questions and considering whether your child’s behavior is consistent with ADHD or not, think about how often the behavior is happening and how intense it is. When a child has ADHD, there is a long-standing, high frequency, chronic nature to the concerning behaviors. If this is the case for your child, it may be time to contact your doctor. He or she can point you in the right direction from there, and may recommend a consultation with an ADHD Center or developmental-behavioral specialist.

Females with ADHD: Can we increase diagnostic accuracy by shifting our conceptual model?

Ellen Littman, Ph.D.

Until 2013, ADHD was still grouped with the Disruptive Behavior Disorders of Childhood in the DSM-IV. Early clinic referrals revolved around the management of hyperactive, impulsive young boys. Treatment focused on minimizing the negative impact of their behaviors on others. Over time, criteria were modified and exemplars constructed in efforts to reflect the changing literature. As long as observable behaviors serve as our yardstick, the females presenting most similarly to hyperactive boys are most likely to be diagnosed. Indeed, in the early 90’s, a keynote speaker concluded that so few girls were diagnosed because girls were simply “ADD wannabees”. In other words, most girls failed to meet the male-based criteria by age 7. Still, the presumption is that the criteria pertain as accurately to females as to males.

We come by this unintended gender bias honestly—and it is embedded in the very fabric of our science. Unfortunately, one of the consequences of this bias is that combined type females are still more likely to be diagnosed than inattentive females because they are more likely to meet criteria by age 12. They are also more likely to comprise the majority of female clinic subjects chosen for study samples. As a result, we’re honing our skills in recognizing the impulsive girls; however, recognizing the subtle and complex presentations of inattentive females remains far more elusive.

Gender differences?

The research says that there are no significant gender differences in terms of number of symptoms, severity, persistence, academic achievement, number of comorbidities, efficacy and tolerability of meds; even the manifestations of symptoms are similar. Indeed, the disorder itself does not differ by gender–but the genders themselves differ–physiologically, psychologically, socio-culturally. For example, women with ADHD exhibit more anxiety and depression than men with ADHD, but women in general exhibit more anxiety and depression than men. The same symptoms are experienced, but females perceive greater impairment than males. Some wonder if females are more vulnerable to the impairing effects of ADHD symptoms because it is often their functional challenges rather than the symptoms themselves that cause them to seek treatment. Misattributing their difficulties to characterological flaws, females judge themselves harshly and label themselves as inadequate relative to peers.

A unique trajectory

Several factors contribute to our diagnostic challenges. The greater likelihood of inattentive symptoms results in subtler gender-typical presentations. Internalized symptoms like anxiety and depression often contribute to misdiagnosis. Gender role expectations reward those conforming to the feminine ideal without complaint. Women with poorly choreographed executive functions mask their struggles and are too ashamed to ask for help. Ironically, the result of compensating successfully is that their plight remains secret but no less damaging to their sense of self.

Stable over time?

Historically, ADHD has been considered a neurodevelopmental disorder that is stable over time, but the women’s story is more complex. Actually, across the lifespan, symptoms tend to improve, as do executive functions. However, their qualitative experience varies considerably in response to hormonal fluctuations. Diagnosis is often delayed until girls’ symptoms intensify after puberty. Within a given month, the motivated and assertive woman presenting 4 days after her period has little resemblance to the insecure and demoralized woman presenting 4 days before her period. Hormones also mediate the emotional volatility of adolescent girls, exacerbating observable anxiety and depression, which can easily lead to misdiagnosis. Estrogen exacerbates ADHD symptoms while also affecting sleep, verbal memory, mood, and the dopamine reward system.

Undiagnosed, dysfunctional coping strategies segue into comorbid disorders that are cumulative over time across multiple domains; self-esteem plummets, anxiety paralyzes, depression deepens, and stigma is internalized. Demoralization can lead to despair, which contributes to the shocking gender differences in impact: poor self-care, self-harm, intimate partner violence, suicidality, and early mortality. The severity of these potential outcomes underscores our responsibility to address this public health crisis.

Increasing inclusiveness

Despite the fact that girls are less frequently referred, less frequently identified, and less frequently meet DSM criteria, more females than ever are being diagnosed. However, rather than disrupt, most struggle with increasingly complex quality of life issues that primarily affect them and their sense of self. The daunting array of potential negative outcomes highlights a developmental trajectory that differs significantly from those of control women and ADHD men. Recent studies compare females with ADHD to female controls, with an eye towards reducing bias. Using population samples may enlarge the subset of females that are studied. Perhaps the behavior of one gender cannot be the standard by which the other is measured. By assessing functional impairment and internalized symptoms in addition to behavior, it may be possible to create a system that can recognize symptoms in a far greater percentage of our population with equal accuracy and simultaneously allow us greater attunement to the impairments that color their quality of life.

References

Haimov-Kochman, R., & Berger, I. (2014). Cognitive functions of regularly cycling women may differ throughout the month, depending on sex hormone status; a possible explanation to conflicting results of studies of ADHD in females. Frontiers in human neuroscience, 8, 191.

Hinshaw, S. P., Owens, E. B., Zalecki, C., Huggins, S. P., Montenegro-Nevado, A. J., Schrodek, E., & Swanson, E. N. (2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: Continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of consulting and clinical psychology, 80(6), 1041.

Nadeau, K. G., Littman, E., & Quinn, P. O. (2015). Understanding girls with ADHD: How they feel and why they do what they do. Advantage Books: Washington, DC .

Rucklidge, J. J. (2010). Gender differences in attention-deficit/hyperactivity disorder. Psychiatric Clinics, 33(2), 357-373.

Quinn, P. O., & Madhoo, M. (2014). A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. The primary care companion for CNS disorders, 16(3).

Williamson, D., & Johnston, C. (2015). Gender differences in adults with attention-deficit/hyperactivity disorder: A narrative review. Clinical psychology review, 40, 15-27.

CCHMC Center for ADHD

Tanya Froehlich, M.D., M.S.
Associate Professor of Pediatrics
Cincinnati Children’s Hospital Medical Center

Established in 2005, the Center for ADHD at Cincinnati Children’s Hospital Medical Center (CCHMC) is composed of a multi-disciplinary team of investigators across several divisions including Behavioral Medicine and Clinical Psychology, Developmental and Behavioral Pediatrics, and General and Community Pediatrics. Our Center is one of the largest centers in the country devoted entirely to improving the care of children and adolescents with ADHD. The Center is actively involved in providing state-of-the-art, evidence-based assessment and treatment services for children and adolescents with ADHD, as well as working with community-based organizations to improve care for children with ADHD. Clinical services offered by our Center include comprehensive evaluations and consultation for children and teens, parent group interventions for preschool and school-aged children, academic skills group programs for adolescents in grades 6-10, and frustration management groups for children aged 8 to 11 years old. We also offer a 7-week Summer Treatment Program (STP) for children aged 7-12 years of age. The Center serves over 400 patients per year across these clinical services.

In addition to our clinical services, our Center has eleven current research projects federally-funded by the National Institutes of Health (NIH), the Institute of Education Sciences (IES), and Agency for Healthcare Research and Quality (AHRQ). This research focuses primarily on developing new and innovative ways to understand, evaluate and treat ADHD. Examples of the exciting research at the Center for ADHD include: a) an NIH-funded randomized, double–blind, placebo-controlled trial designed to study the neurobehavioral effects of methylphenidate (MPH) treatment; b) an NIH-funded randomized clinical trial examining the effectiveness of a driving intervention to address ADHD-related driving impairment in ADHD teens; c) an IES-funded study examining the impact of sleep problems on the academic and social functioning of adolescents with and without ADHD across the transition from middle to high school; d) an AHRQ-funded randomized clinical trial testing the effectiveness of an online behavioral intervention for elementary-school aged children with ADHD; e) IES- and NIH-funded studies evaluating academic, socioemotional, and neuropsychological-related impairments experienced by children with sluggish cognitive tempo; f) an NIH-funded study to develop intervention strategies to address medication adherence in teens with ADHD; g) an NIH-funded study that will adapt an academic-focused executive functioning intervention with demonstrated effectiveness in young adolescents with ADHD for middle school students with high-functioning autism; h) an NIH-funded study to determine genetic predictors of methylphenidate response.

Our Center has also developed and tested Internet-based software (mehealth for ADHD) to improve the quality of ADHD care of community-based pediatricians nationwide. This software a) facilitates online collection of parent and teacher rating scales, b) promotes parent-teacher-pediatrician communication, c) provides feedback to pediatricians regarding their provision of quality ADHD care, and d) gives access to quality improvement tools. Two clinical trials have demonstrated that use of the software dramatically improves evidence-based ADHD care among community-based pediatricians and significantly improves the treatment outcomes of children treated by pediatricians using the software. Our Center for ADHD currently supports the software which is used by approximately 600 pediatricians nationwide.