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PubMed2004

A prospective, multicenter, open-label assessment of atomoxetine in non-North American children and adolescents with ADHD.

OBJECTIVE: The aim of this study was to study treatment response to atomoxetine in a large, multicenter study of non-North American patients with ADHD. METHODS: A total of 604 children and adolescents with ADHD were enrolled in a 10-week open-label trial with atomoxetine prior to randomization to a double-blind relapse prevention phase at 33 sites in the United Kingdom, continental Europe, Israel, South Africa, and Australia. All patients had ADHD symptom severity at least 1.5 standard deviations above United States age and gender norms for their diagnostic subtype as measured by the investigator-scored ADHD Rating Scale (ADHD RS). Outcomes were assessed by analysis of change in the ADHD RS; functional and psychosocial outcomes were assessed using the Child Health Questionnaire (CHQ). RESULTS: At endpoint, ADHD RS total scores decreased by an average of 56.7%, and 69% of patients were rated as having no or minimal symptoms. Significant improvement was observed in psychosocial and functional outcomes. Discontinuations attributed to adverse events were < 4%. CONCLUSION: These open-label data, gathered in an international setting, add to our knowledge of the value of atomoxetine in treating ADHD symptoms, as well as its safety and tolerability.

Adolescent↗

PubMed2001

Reassessment of ADHD in a historical cohort of children treated with stimulants in the period 1969-1989.

The operational diagnostic criteria for ADHD or HKD were not at hand in Denmark before 1994, when WHO's International Classification of Diseases -10 (ICD-10) was introduced. The criteria for ADHD/HKD were well known at our clinic, but when treating children with stimulants the criteria used clinically prior to 1994 were less specific than today. The aims of this paper are to examine the prevalence of ADHD in a historical cohort of children treated with stimulants during the period 1969-1989 and to reassess a wide range of comorbid disorders and sociodemographic characteristics in order to compare aspects of the given treatment with the modern recommendations. At our clinic 208 children (183 boys) were given stimulants during the period 1969-1989. Case records on these probands were reassessed retrospectively for DSM-IV criteria regarding ADHD and comorbid disorders as well as for characteristics of stimulant treatment. Sixty-five percent met full criteria for an ADHD diagnosis. Including Subthreshold ADHD as many as 81 % of the cohort were re-diagnosed with ADHD. Prevalence rates of conduct problems and anxiety disorder were similar to previous prospective ADHD studies. The use of stimulants during the period 1969-1989 were in accord with modern guidelines. This cohort is comparable to other clinically based ADHD cohorts as regards inattentive, hyperactive/impulsive symptoms, comorbidity, impairment, gender differences, intelligence and socio-economic status (SES).

Adolescent↗

PubMed1994

Genetic factors in substance abuse based on studies of Tourette syndrome and ADHD probands and relatives. I. Drug abuse.

There have been relatively few studies of genetic factors in drug abuse. Childhood Attention Deficit Hyperactivity Disorder (ADHD) has been implicated as a risk factor, and pedigree studies of Tourette Syndrome (TS), a hereditary impulse disorder closely related to ADHD, show an increased prevalence of substance abuse in relatives. These observations suggest the genes for TS and ADHD may play an important role in the development of drug abuse. To examine this hypothesis 217 TS probands and 328 of their relatives, 58 ADHD probands and 35 of their relatives, and 50 controls were prospectively studied using a structured questionnaire based on the Diagnostic Interview Schedule. All subjects were Caucasians 16 to 49 years of age. The responses concerning the use of 8 different drugs and 8 different symptoms of drug abuse were compared. The results showed a highly significant increase in positive responses with increased loading for the TS and ADHD genes for 6 of the 8 drugs and all of the drug abuse symptoms. The percentage of positive responses in TS probands was markedly influenced by the presence of comorbid ADHD, as well as discipline, obsessive-compulsive, or alcohol problems. These results suggest that the genes responsible for TS and ADHD play an important role in drug abuse/dependence. The dopamine D2 receptor gene (DRD2) appears to be one of these genes since variants at this locus are significantly increased in frequency in TS, ADHD, conduct disorder and drug abuse.

Adolescent↗

PubMed2004

The impact of specific language impairment on working memory in children with ADHD combined subtype.

The objective of this study was to examine the impact of comorbid specific language impairment (SLI) on verbal and spatial working memory in children with DSM-IV combined subtype Attention Deficit Hyperactivity Disorder (ADHD-C). Participants were a clinical sample of 812- to 1212-year-old children diagnosed with ADHD-C. A group of ADHD-C with SLI was compared to a group of ADHD-C without SLI, and a group of normal children, matched on age and nonverbal intelligence. The results show that ADHD-C children with SLI scored significantly lower than those without SLI and normal children, on verbal working memory measures only. Both ADHD groups performed normally on spatial working memory measures. It is concluded that working memory deficits are not a specific characteristic of ADHD but are associated with language impairments. The importance of screening for language disorders in studies of neuropsychological functioning in children with ADHD is emphasized.

Adolescent↗

PubMed2006

Association between alpha-2a-adrenergic receptor gene and ADHD inattentive type.

BACKGROUND: Previous investigations have demonstrated that an MspI polymorphism at the adrenergic alpha2A receptor gene (ADRA2A) is associated with severity of attention-deficit/hyperactivity disorder (ADHD) inattentive symptoms in clinical samples composed mainly of subjects with ADHD, combined type. This study aimed to investigate the association between this ADRA2A polymorphism and attention-deficit/hyperactivity disorder-inattentive type (ADHD-I) in a nonreferred sample. METHODS: In a case-control study, we assessed a sample of 100 children and adolescents with ADHD-I and 100 non-ADHD controls. Cases and controls were matched by gender and age and were screened by using teacher reports in a revised version of the Swanson, Nolan, and Pelham rating scale at 12 schools. Psychiatric diagnoses were derived through structured diagnostic interviews. RESULTS: Homozygous subjects for the G allele at the ADRA2A had significantly higher odds ratio (OR) for ADHD-I than did those with other genotypes (CC + CG genotypes), even after adjusting for potential confounders (p = .02; OR = 3.78; 95% confidence interval = 1.23-11.62). In family-based analyses, no significant associations were detected. CONCLUSIONS: Our results suggest that the ADRA2A may be associated with ADHD-I, replicating previous findings from clinical samples that have suggested the importance of this gene for the dimension of inattention. In addition, these results support the role of the noradrenergic system in ADHD.

Adolescent↗

PubMed2006

Impact of ADHD on the neurocognitive functioning of adolescents with bipolar disorder.

BACKGROUND: Pediatric Bipolar Disorder (BD) has been associated with a number of neurocognitive deficits not dissimilar to ADHD. This study compared neuropsychological profiles of 4 groups of adolescents (14-17 years): 41 Normal Controls (NC), 30 ADHD, 12 BD and 12 combined (BD+ADHD). METHODS: Participants were identified according to a standardized protocol (WASHU-KSADS mood section, K-SADS-PL and Conners Scales) and completed tests of processing speed, memory, executive functioning, set shifting, and inhibition. ADHD adolescents on stimulant medication did not take it on the day. RESULTS: After controlling for covariates, the ADHD-only and combined groups were most impaired, including processing and naming speed, working memory, and response inhibition. The ADHD-only group showed specific impairment in naming objects, numbers and letters than the NC and showed greater deficits than the BD-only group on tests of naming speed. The combined group showed greatest deficits in verbal memory and inhibitory control. Other than working memory, there were no differences between the BD-only and NC groups. Removal of BD-NOS did not impact on the results. CONCLUSIONS: This study failed to find broad neurocognitive deficits in BD-only adolescents. Only those with comorbid ADHD showed cognitive deficits, highlighting the impact ADHD may have on neurocognitive functioning of BD.

Adolescent↗

PubMed2004

Sex differences in adult ADHD: a double dissociation in brain activity and autonomic arousal.

It is now estimated that up to one-half of attention deficit hyperactivity disorder (ADHD) children continue to manifest symptoms in adulthood. A striking discrepancy between juvenile and adult populations is the increasing proportion of females with an ADHD diagnosis. To shed light on the psychophysiological mechanisms underlying adult ADHD, electroencephalography (EEG) and electrodermal index of arousal (skin conductance level or SCL) measures were employed under conditions of eyes-closed resting activity. Quantitative EEG (QEEG) and SCL were measured simultaneously and continuously (2 min) in 35 ADHD adults (21 males, 14 females) and their age- and sex-matched controls. As a group ADHD adults were found to have EEG and SCL deviations consistent with previous adolescent and juvenile studies. However, adult males (but not females) with ADHD showed increased EEG theta activity. By contrast, adult females (but not males) with ADHD were autonomically hypo-aroused (decreased SCL). These results suggest that distinct mechanisms may underpin adult ADHD in males and females.

Adult↗

PubMed2005

Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms.

The purpose of the present study was to examine the potential efficacy, patient acceptability, and feasibility of a novel, cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. Thirty-one adults with ADHD and stable psychopharmacology for ADHD were randomized to CBT plus continued psychopharmacology or continued psychopharmacology alone. Assessments included ADHD severity and associated anxiety and depression rated by an independent evaluator (IE) and by self-report. At the outcome assessment, those who were randomized to CBT had lower IE-rated ADHD symptoms (p < .01) and global severity (p < .002), as well as self-reported ADHD symptoms (p < .0001) than those randomized to continued psychopharmacology alone. Those in the CBT group also had lower IE-rated and self-report anxiety (p's < .04), lower IE-rated depression (p < .01), and a trend to have lower self-reported depression (p = .06). CBT continued to show superiority over continued psychopharmacology alone when statistically controlling levels of depression in analyses of core ADHD symptoms. There were significantly more treatment responders among patients who received CBT (56%) compared to those who did not (13%) (p < .02). These data support the hypothesis that CBT for adults with ADHD with residual symptoms is a feasible, acceptable, and potentially efficacious next-step treatment approach, worthy of further testing.

Adult↗

PubMed2005

Treatment of methadone-maintained patients with adult ADHD: double-blind comparison of methylphenidate, bupropion and placebo.

The purpose of this double-blind, three-arm, 12-week trial was to compare the efficacy of sustained-release methylphenidate or sustained-release bupropion to placebo in treating adult attention deficit hyperactivity disorder (ADHD) symptoms. The randomized sample consisted of 98 methadone-maintained patients who were pre-dominantly male (57%) and 40% Caucasian, 40% Hispanic and 20% African American. All participants met DSM-IV criteria for adult ADHD, with 53% meeting DSM-IV criteria for cocaine dependence/abuse. In addition to medication and treatment as usual at a methadone program, individuals received weekly individual cognitive behavioral treatment. Other than current employment status, there were no significant demographic differences across the three treatment groups. Seventy percent completed the 12-week trial. There were no differences in retention rate based on treatment group. A reduction in ADHD symptoms using the adult ADHD rating scale was observed in all three groups, but there were no significant differences in outcome between treatments. The placebo response rate was high, with 46% of the placebo group self-reporting substantial improvement in their ADHD symptoms (>30% reduction in adult ADHD rating scale). Using other ADHD outcome measures, the placebo response and medication response rates were substantially lower. There was no evidence of misuse of medication or worsening of cocaine use among those randomized to methylphenidate. Taken together, sustained-release methylphenidate or sustained-release bupropion did not provide a clear advantage over placebo in reducing ADHD symptoms or additional cocaine use in methadone-maintained patients.

Adult↗

PubMed2006

Treatment of cocaine dependent treatment seekers with adult ADHD: double-blind comparison of methylphenidate and placebo.

The purpose of this double-blind 14-week trial was to compare the efficacy of sustained-release methylphenidate (MPH) to placebo (PBO) in treating adult attention deficit hyperactivity disorder (ADHD) symptoms in current cocaine dependent (CD) treatment seekers. The randomized sample consisted of 106 participants who were predominately male (83%) and 60% Caucasian, 14% Hispanic, 20% African-American and 6% other. All participants met DSM-IV criteria for ADHD and CD. There were no significant demographic differences between the two treatment groups. All participants received weekly individual cognitive behavioral therapy. There was no difference in retention rate based on treatment group (p=.91). The majority of the PBO group and the MPH group reported >30% improvement in their ADHD symptoms (55% versus 47%), with no significant difference between the two groups (p=.44). Using a combined outcome measure (>30% reduction in ADHD symptoms and CGI <3), the response rates were similar for both groups (28% PBO versus 30% MPH; p=.83). Longitudinal analyses of the urine toxicology data using generalized estimating equations, revealed a decrease in the probability of cocaine positive urine samples during the trial for the MPH group compared to the PBO group (p=.001). Further analysis suggested that for the MPH group, ADHD treatment responders, based on a semi structured clinical interview, were more likely to have a reduction in cocaine use compared to the non-ADHD responders. Although sustained-release MPH did not show superiority over PBO in treating ADHD symptoms, this trial provides some evidence that improvement in ADHD symptoms (clinician rated) among those patients receiving MPH, but not placebo, was associated with a reduction in cocaine use.

Adolescent↗

PubMed2006

Questionnaire ratings of attention-deficit/hyperactivity disorder (ADHD) in adults are associated with spatial working memory.

OBJECTIVE: Data related to brain function may have the potential to improve the reliability and validity of assessments for the aetiologically and clinically heterogeneous syndrome of attention-deficit/hyperactivity disorder (ADHD). This study investigated associations between questionnaire assessments of behavioural features of adults with ADHD and an aspect of neurocognitive performance which has been reported to be impaired in adults with ADHD. METHODS: Fifty-nine adult patients with a DSM-IV diagnosis of ADHD, and their informants, completed questionnaires related to aspects of severity of ADHD. Associations were examined between questionnaire ratings and performance on a computer-administered task of spatial working memory (SWM). RESULTS: Correlations between ratings of ADHD and SWM indicated moderate but significant correlations for patients' ratings, but not for informants' ratings. Also, patients who reported a past history of 'self-harm' (N=33) had a significantly worse mean performance on both measures of SWM (p=0.004, 0.003). CONCLUSIONS: The results indicate that aspects of impulsivity, i.e. self-ratings of 'emotive' behaviour (involving rapid response to stimuli and marked reactivity of mood) and of past 'self-harm', show relatively strong associations with SWM performance in adults selected on the basis of an ADHD diagnosis. A profile of neurocognitive performances may have a role in the assessment of ADHD.

Adult↗

PubMed2006

Obesity and ADHD may represent different manifestations of a common environmental oversampling syndrome: a model for revealing mechanistic overlap among cognitive, metabolic, and inflammatory disorders.

Obesity and attention-deficit hyperactivity disorder (ADHD) are both increasing in prevalence. Childhood exposure to television has shown linkage to both ADHD and obesity with the former ascribed to dysfunctional cognitive hyperstimulation and the latter to altered patterns of diet and exercise. Empirical evidence has contradicted prior presumptions that the hyperactivity of ADHD would decrease the risk of obesity. Instead, obesity and ADHD demonstrate significant comorbidity. We propose that obesity and ADHD represent different manifestations of the same underlying dysfunction, a phenomenon we term environmental oversampling syndrome. Oversupply of information in the form of nutritional content and sensory content may independently predispose to both obesity and ADHD. Moreover, the pathogenic mechanisms of these conditions may overlap such that nutritional excess contributes to ADHD and cognitive hyperstimulation contributes to obesity. The overlapping effects of medications provide further evidence towards the existence of shared etiologic pathways. Metabolism and cognition may represent parallel systems of intelligence, and oversampling of content may constitute the source of parallel dysfunctions. The emerging association between psychiatric and metabolic disorders suggests a fundamental biologic link between these two systems. In addition, the immune system may represent yet another form of intelligence. The designation of syndrome X subsumes seemingly unrelated metabolic and inflammatory entities. Environmental oversampling syndrome may represent an even more inclusive concept that encompasses various metabolic, inflammatory, and behavioral conditions. Apparently disparate conditions such as insulin resistance, diabetes, hypertension, syndrome X, obesity, ADHD, depression, psychosis, sleep apnea, inflammation, autism, and schizophrenia may operate through common pathways, and treatments used exclusively for one of these conditions may prove beneficial for the others.

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

Electrophysiological evidence of enhanced distractibility in ADHD children.

Abnormal involuntary attention leading to enhanced distractibility may account for different behavioral and cognitive problems in children with attention deficit hyperactivity disorder (ADHD). This was investigated in the present experiment by recording event-related brain potentials (ERPs) to distracting novel sounds during performance of a visual discrimination task. The overall performance in the visual task was less accurate in the ADHD children than in the control children, and the ADHD children had a higher number of omitted responses following novel sounds. In both groups, the distracting novel sounds elicited a biphasic P3a ERP component and a subsequent frontal Late Negativity (LN). The early phase of P3a (180-240 ms) had significantly smaller amplitudes over the fronto-central left-hemisphere recording sites in the ADHD children than in the control group presumably due to an overlapping enhanced left-hemisphere dominant negative ERP component elicited in the ADHD group. Moreover, the late phase of P3a (300-350 ms) was significantly larger over the left parietal scalp areas in the ADHD children than in the controls. The LN had a smaller amplitude and shorter latency over the frontal scalp in the ADHD group than in the controls. In conclusion, the ERP and behavioral effects caused by the novel sounds reveal deficient control of involuntary attention in ADHD children that may underlie their abnormal distractibility.

Acoustic Stimulation↗

PubMed2005

Dissecting the attention deficit hyperactivity disorder (ADHD) phenotype: sustained attention, response variability and spatial attentional asymmetries in relation to dopamine transporter (DAT1) genotype.

ADHD is a childhood-onset behavioural disorder with a heterogeneous profile of neuropsychological impairment. Neuropsychological heterogeneity may, in part, reflect underlying genetic differences. Here we examined sustained attention, response variability and spatial attentional asymmetries in a sample of children and adolescents with ADHD (n=22) in relation to dopamine transporter genotype (DAT1) and also controls (n=20). Participants performed the sustained attention to response task (SART) (testing sustained attention and response variability) and the greyscales task (a perceptual measure of attentional bias). The latter has previously been shown to yield a robust leftward attentional asymmetry in healthy subjects. The 10-repeat allele of the DAT1 gene has been associated with ADHD in a number of studies and appears to have biological significance. The ADHD group was sub-divided into those individuals with two copies of the "high-risk" 10-repeat allele (high-risk DAT1) versus those with one or no copies of this allele (low-risk DAT1). The high-risk DAT1 ADHD group displayed greater response variability on the SART than either the low-risk DAT1 group or healthy controls, whereas the latter two groups did not differ. Further, the high-risk DAT1 group showed an attenuated spatial asymmetry, relative to the low-risk DAT1 ADHD group, who showed the typical leftward attentional asymmetry. Our results suggest that the 10-repeat DAT1 allele may mediate neuropsychological impairment in ADHD. The application of molecular genetics may help to define neuropsychological impaired subgroups of ADHD.

Adolescent↗

PubMed2006

The cognitive genetics of attention deficit hyperactivity disorder (ADHD): sustained attention as a candidate phenotype.

Here we describe the application of cognitive genetics to the study of attention deficit hyperactivity disorder (ADHD). Cognitive genetics owes much to the pioneering work of cognitive neuropsychologists such as John Marshall, whose careful observations of cognitive dissociations between brain-lesioned patients greatly advanced the theoretical understanding of normal cognitive function. These theories have in turn helped to constrain linkages between candidate genes and cognitive processes and thus help to drive the relatively new field of cognitive genetics in a hypothesis-driven fashion. We examined the relationship between sustained attention deficits in ADHD and genetic variation in a catecholamine-related gene, dopamine beta hydroxylase (DbetaH). DBH encodes the enzyme that converts dopamine to noradrenaline and is crucial to catecholamine regulation. A polymorphism with the DBH gene has been associated with ADHD. In fifty-two children with ADHD, we examined whether variation in the Taq I DBH gene polymorphism was related to sustained attention performance. Participants performed the Sustained Attention to Response Test (SART). Performance on the SART discriminates ADHD from control children, and in imaging work, is associated with right frontoparietal activation. A significant effect of DBH genotype was found on SART performance measures. Children possessing two copies of the ADHD-associated risk allele (A2) had significantly poorer sustained attention than those ADHD children who did not possess this allele or a non-genotyped control group. The DBH gene may contribute to the susceptibility for ADHD, in part because of its varying effects on the development of brain mechanisms mediating sustained attention.

Adolescent↗

PubMedDate not supplied

Evidence for anomalous lateralization across domain in ADHD children as well as adults identified with the Wender Utah rating scale.

Two studies assessed the relation between ADHD symptomatology and correlates of cerebral dominance. In the first, laterality was examined in school children (N=57), 28 with ADHD. Parental reports of greater attentional symptoms were related to non-righthandedness, but teacher reports were related to anomalous laterality of foot, ear and eye, as well as hand. This suggests that the previously reported association between ADHD and non-righthandedness may not be unique, but instead indicative of a more general condition of anomalous lateralization. This possibility was examined in study two, in which 234 undergraduates were assessed. As expected, the 26 adults identified by the Wender Utah Rating Scale (WURS) as retrospectively reporting more ADHD characteristics were found to be generally male. Also, in a replication of study one, enhanced WURS scores were associated with anomalous lateralization beyond handedness. In this case, ADHD characteristics were associated with a shift away from a right bias for hand, foot, and ear, but not eye. Factor analysis of the extensive Steenhuis and Bryden handedness questionnaire was then undertaken to determine whether all aspects of handedness, or only a subset, are associated with ADHD. The factor analysis indicated that the retrospective reports of ADHD characteristics were associated with only two of the three dimensions. Though limitations such as the gender composition of the groups in study one tempers the conclusions, the results of both studies support previous findings that ADHD is associated with anomalous laterality, but also indicate that non-righthandedness is not an adequate characterization of this relationship.

Adult↗

PubMed2000

Motor control and state regulation in children with ADHD: a cardiac response study.

The goal of the current study was to investigate whether poor motor control in children with Attention-Deficit Hyperactivity Disorder (ADHD) was associated with a state regulation deficit. For this purpose, 28 ADHD and 22 healthy children carried out two Go No-Go tests: one with a fast stimulus presentation rate, and the other with a slow stimulus presentation rate. Groups were compared on RT performance and on specific cardiac measures, reflecting arousal, motor activation/inhibition, and effort allocation. No group difference in the arousal measure (mean heart rate) was found. Further, groups did not differ with respect to response inhibition: in both the fast and slow condition, ADHD children made comparable numbers of errors of commission to the control group, and the groups did not differ with respect to the heart rate deceleration after the onset of the No-Go signal, reflecting motor inhibition. Group differences were found with respect to motor activation and effort allocation in the condition with a slow presentation rate. In this condition: (1) ADHD children reacted more slowly to Go signals than control children, suggesting poor motor activation; (2) the heart rate deceleration before the onset of Go signals, which is believed to reflect motor preparation, was less pronounced in the ADHD children; (3) after Go signals, where a response was given, the cardiac shift from deceleration to acceleration, indicating response initiation, was delayed in ADHD children; and (4) ADHD children had greater heart rate variability (0.10 Hz component) than the control group, indicating that less effort was allocated. No group differences in motor activation and effort allocation were found in the condition with a fast presentation rate of stimuli. We conclude, therefore, that a slow presentation rate of stimuli brings the ADHD child in a non-optimal activation state.

Arousal↗

PubMed2001

Executive function in fluency and recall measures among children with Tourette syndrome or ADHD.

This study assessed two relevant aspects of executive dysfunction in children with either Tourette syndrome (TS) or ADHD. Process variables derived from existing neuropsychological measures were used to clarify the executive function construct. Clustering of responses on measures of verbal fluency, figural fluency, and verbal learning was examined to assess strategic response organization. Rule breaks, intrusions, and repetition errors were recorded to assess inhibition errors. No significant differences were found among the three groups (TS, ADHD, and controls) on tasks of response organization (clustering). In our sample, both the ADHD and the TS groups were largely free from executive function impairment, and their performance on the fluency and list learning tasks was in the average range. There was a significant group difference on one of the disinhibition variables, with both TS and ADHD groups showing significantly more intrusions on verbal list learning trials than controls. When more traditional total score variables were analyzed among the three groups, there were no significant differences; however, analysis of effect size revealed medium-to-large effect sizes for Letter Word Fluency total score differences (ADHD vs. controls), and for Semantic Word Fluency total score differences (ADHD vs. TS), with the ADHD group having weaker performance in both comparisons. Results provide some support for the use and analysis of process variables-particularly those related to inhibition and intrusion errors, in addition to the total score variables when assessing executive function deficits in children with ADHD and TS. While group differences may be found, children with uncomplicated TS should not routinely be considered to have significant executive function impairments, and when deficits are found, they may be attributable to other comorbid disorders.

Attention Deficit Disorder with Hyperactivity↗