ADVANCED

ADHD
STIMULANT
A LT E R N AT I V E S
I N P E D I AT R I C
PRIMARY CARE

ABIGAIL SCHLESINGER, MD
THE FACES OF AD/HD

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OUTLINE

Switching stimulants
Stimulant alternatives
Cases
Guidance/Anticipatory Guidance

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SWITCHING
STIMUL ANTS
JOHNNY – 7 TH GRADE CRASH
• Johnny is a 13 year old male with ADHD and no comorbidities. He has responded so
well to Adderall XR 30mg in the past that he has not needed therapy for over 2 years.
In the summer before 7th grade his insurance changed, and Adderall XR was no longer
covered. Mom tells you she had heard good things about Concerta, which was covered
with no co-pay. She has never thought that the medication worked after school. She
also had concern about 7th grade being “harder due to more homework and having to
switch between classes.” She hopes that Concerta 36mg would work longer in the day
than Adderall XR.
JOHNNY – 7 TH GRADE CRASH

• Mom and Johnny come in today for a follow-up stating that 7th grade has been even
worse than they anticipated, and they want to switch back to Adderall XR 30mg from
the Concerta 36mg that he started over the summer.

• What happened and what will you do next?

APPROACH TO TREATMENT
A P P ROAC H TO T R E AT M E N T
D I AG N O S T I C T H E O RY
• Developmental Context, Environment Diagnostic
Theory
• Diagnosistic Theory

Monitor Treatment
Developmental Response Targets
Context &
Environment

Diagnostic
Theory
Intervention

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JOHNNY – WHAT HAPPENED
• Developmental Context & Environment– 7 th grade is different, more expectations,
more homework, less support from teachers. No other trauma, no other concerns
other than some increased irritability/arguing that is only with mom

• Diagnosis – no evidence of anything other than ADHD(vanderbilts clearly reveal ADHD

symptoms, although some ODD symptoms are appearing in the teacher reports – this
is new)

• Treatment targets – what does “it’s worse then we expected” means

– What does mom think the one thing is that got in the way – and is it an ADHD core
symptom amenable to a pharmacologic or nonpharmacologic intervention
JOHNNY WHAT HAPPENED
• Treatment targets – completion of homework
– Better ability to attend to what homework is in class

• Treatment Recommendations
– Environment – requirements of 7th grade were more
• Does he need an IEP/504 plan – to support sitting in the front, extra help in school with homework
• Does he need a new approach to after school work
– Medication
• Concerta 36mg is not equal to adderall xr 30mg
• Adderall XR 30mg equivalent to at least concerta 54mg (maybe 72mg or higher)
• Adderall XR 10mg = Adderall 5 twice a day(total=10mg) = Ritalin 20mg three times a day
CONVERTING BETWEEN STIMULANTS
1. Estimate Total daily dose
– Methylphenidate relationship to amphetamine(In terms of total daily
Dose)
– Which are enantiomers and which are not(enantiomers are always
half the dose)
• Which medications do not follow the rules?
2. Length of action - Decide how far apart you think medication should
be given by length of action
– Short, “Longer short”, intermediate, long
– How long do they actually work for the child?
3. Convert to long-acting if needed
• Break up dose throughout the day based on how long they act
Adj t f th th t d ’t f ll th l
AMPHETAMINE & METHYLPHENIDATE
TOTAL DAILY DOSES
• Adderall(amphetamine product) Total Daily Dose is generally equivalent
to ½ of Ritalin(methylphenidate product) dose(except enantiomer)

– Ritalin 10mg twice a day= Ritalin 20mg a day

– Adderall 20mg a day converts to a total of adderall product 10mg a
day

• Enantiomers - Focalin (DEXmethylphenidate)

– Ritalin 10mg twice a day = total daily dose of ritalin 20mg day
– Ritalin 20mg a day = focalin (DEXmethylphenidate) 10mg
 LENGTH OF ACTION
Amphetamine Methylphenidate
Short-acting Ritalin , Methylin, methylphenidate
– 4 hours
*Focalin

Longer short acting- Adderall, Evekeo, Zenzedi,

– 4-6 hours Procentra, ampethamine, mixed
amphetamine salts

Intermediate Acting Metadate CD

--6-8 hours
*Focalin XR

Long-Acting Adderall XR(mixed amphetamine Quillivant(liquid), Quillichew, Aptensio

--10-12 hours salts ER/XR) XR
*Enantiomer **Adzenys XR-ODT Concerta
**Unique equivalency rule **Vyvanse
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“PUTTING IT TOGETHER”
Amphetamine Methylphenidate
Short-acting Ritalin 20mg tid
Methylin 20 mg bid - tid
*Focalin 10 mg bid - tid

Intermediate-acting Adderall, Evekeo, Zenzedi, Metadate CD 40mg plus afterrnoon

Procentra 15 mg bid dose of ritalin 20
*Focalin XR 30mg plus afternoon dose
of focalin 10
Long-Acting Adderall XR 30mg Quillivant 60 mg(note 25mg/5ml)

**Adzenys XR-ODT 18.8mg Quillichew 60 mg

*Enantiomer **Aptensio XR 60mg(actually equiv to
ritalin 25.9 twice a day)
*Enantiomer **Vyvanse 70mg (more similar to **Concerta 54mg-72mg or more
**Unique equivalency rule Ritalin 20mg tid or Adderall XR
30mg)
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 STIMULANTS ROUGH EQUIVALENCY
Amphetamine Methylphenidate
Short-acting Ritalin 20 mg bid - tid
*Focalin 10 mg bid - tid
Intermediate-acting Adderall, Evekeo, or Zenzedi , or Metadate CD 30mg + afternoon dose
Procentra15 mg bid to euqual tid dosing
*Focalin XR 30mg

Long-Acting Adderall XR 30mg Quillivant 60 mg(note 25mg/5ml), or

Quillichew 60mg
**Adzenys XR-ODT 18.8mg
*Enantiomer **Aptensio XR 60mg(actually equiv to
ritalin 25.9 twice a day)
**Unique equivalency rule **Vyvanse 70mg (more similar to **Concerta 54mg-72mg or more
Ritalin 20mg tid or Adderall XR
30mg)

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STIMULANTS – ROUGH EQUIVALENCY
• Methylphenidate 1 mg is roughly equivalent to 0.5 mg
Amphetamine salt, Dextroamphetamine or dexmethylphenidate

• Switching from Adderall to Dextroamphetamine or

Methylphenidate
• Start with same total daily dose and titrate up for effect
• Switching from Methylphenidate to Adderall
• Start with one half of total daily dose and adjust based on
effect and adverse effects
• Concerta 18 mg/day is roughly equivalent to
Methylphenidate 15 mg/day
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JOHNNY

1. Estimate total daily dose

– Adderall XR 30mg = total daily dose of Ritalin 60mg
– (actually on concerta 36mg) – Ritalin 30-40
2. Length of action
– Concerta does last 10-12 hours – concerns during school day
– Increase to 54mg and follow-up in 1-2 months
– He may need an afternoon dose of Ritalin
3. Convert to long-acting if needed
1. Already on long-acting
STIMUL ANT
ALTERNATIVES
 TWO (VERY) BROAD CLASSES OF
ADHD MEDICATIONS
• Stimulants • Non-stimulants
• Methylphenidate • Alpha-2 agonists
• Amphetamine and • Atomoxetine
derivatives (Strattera)
• Bupropion (Wellbutrin)
 Stimulant Alternatives/Adjuncts
Alpha-2 Agonists

Short Acting Long-Acting

Clonidine(Catapres) Clonidine ER(Kapvay)

Guanfacine(Tenex) Guanfacine
ER(Intuniv)
Atomoxetine(Strattera)

Bupropion(Wellbutrin)
ALPHA-2 AGONISTS
• These are purported to work in Prefrontal Cortex for
ADHD
• Also work in Brain Stem to decrease sympathetic activity,
decreasing blood pressure
– Side effects are largely from decreasing sympathetic
signaling (i.e., dry mouth, sedation)
– Hypotension
• Not often used as ADHD monotherapy, very often used as
an adjunct – except for impulsive aggression
• Takes weeks to see full effect
ALPHA-2 AGONISTS :
DOSAGE, TREATMENT, AND SIDE EFFECTS
• Useful for residual hyperactivity & impulsivity, insomnia, treatment
emergent tics, & aggression
• Routine Physical ExamVital Signs prior to initiation of Prescriptions
• Contraindications: CAD, impaired liver/renal function
• Side Effects: Rebound HTN/tachycardia, hypotension, sedation,
dizziness, constipation, H/A, fatigue
• Dosage: Start with HS and titrate toward morning(or afternoon)
• Monitor BP, but ECG not routinely necessary
ΑLPHA-2 AGONISTS: PROS & CONS
• Clonidine (Catapres/Kapvay) & Guanfacine (Tenex/Intuniv)
• Pros:
– Moderately effective (residual hyperactivity & impulsivity,
insomnia, treatment emergent tics, & aggression)
• Cons:
– Side Effects: Rebound HTN/tachycardia, hypotension,
sedation, dizziness, constipation, H/A, fatigue, sudden
death in combination with stimulants
– Contraindications: CAD, impaired liver/renal function
ALPHA-2 AGONISTS – DOSING
GUANFACINE (TENEX)
– <45 kg start 0.5mg at bedtime >45 kg start 1mg at bedtime
– Can increase to 0.5 bid-tid for total of
• 2mg(<40mg);3mg(<45mg);4mg(>45kg)
– Benefit in treatment of ADHD in children w/comorbid tic d/o (Scahill
et al 2001 n = 34)
– Benefit in adults w/ADHD comparable to dexedrine (Taylor et al
2001, n = 17)

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LONG-ACTING ALPHA-2 AGONISTS –
DOSING GUANFACINE ER (INTUNIV)
• 1 mg to 7mg (0.05-0.12 mg/kg target weight based dose range)
once daily
– 6-12 not much data over 4mg
– 13 and above not much data over 7mg
• Begin at a dose of 1 mg once daily and adjust 1 mg/week.
• Do not
– Crush, chew or break tablets before swallowing.
– Administer with high-fat meals,
– Substitute with short acting guanfacine 1-1 (different
pharmacokinetic profiles )
– Cross titrate with short acting(stop short acting then start long-
acting)
• Do: discontinue with a taper(1 mg every 3 to 7 days to avoid
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rebound hypertension )
 ALPHA-2 AGONISTS –
DOSING CLONIDINE
• Start - <45kg 0.05mg at bedtime >45kg 0.1mg at bedtime
• Titrate – <40kg 0.2mg; <45 0.3mg; >45 0.4mg
• Sedation decreases with time
• Often only given at bedtime
• Benefit with and w/out MPH in children with Tourettes in
reducing ADHD & tics (Tourette’s Study Group 2003, n = 136)
• Benefit in children w/comorbid MR (Agarwal et al 2001, n = 10)
• Meta-analysis shows decreased effect size compared to
stimulants(Connors et al 1999)
LONG-ACTING ALPHA-2 AGONISTS –
DOSING CLONIDINE ER (KAPVAY)
• Dosing 0.1-0.2 bid at am and bedtime – increase by 0.1 every week
• More common side effects may include: drowsiness, tiredness,
irritability, nightmares, sleeplessness, constipation, dry mouth,
decreased appetite, dizziness.
• Less common side effects may include: low blood pressure, low
heart rate
• Tablets should not be crushed, chewed or broken before
swallowing.
• Do not substitute for other clonidine products on a mg-per-mg
basis, because of differing pharmacokinetic profiles.
•26When discontinuing, taper the dose in decrements of no more
than 0 1 mg every 3 to 7 days
STRATTERA: EFFICACY IN CHILDREN
& ADOLESCENTS
• 24-hour duration of action with once-daily dosing
• Incidence of insomnia comparable with placebo (for
children/adolescents)
• Not contraindicated in patients with tics and anxiety
• Nonstimulant/noncontrolled substance
• May improve some measures of functional outcome (not just core
ADHD symptoms)
• DOSING:
– 0.5 mg/kg qam (e.g. 10mg x4d, then double)
– 1.4mg/kg or 100mg
 STRATTERA: SIDE EFFECTS
• Children and Adolescents:
– Decreased appetite (15%)
• Ave wt loss of 2 – 4 LB in first 3 months, then resume nl growth
– Dizziness (5%)
– Dyspepsia (5%)
– Sedation
– BP/HR
• Adults:
– Anticholinergic side effects (dry mouth, constipation, urinary
retention)
– Sexual (decreased libido, erectile disrurbance, anorgasmia)
– Insomnia
– Nausea and decrease in appetite
– BP/HR
• Liver Toxicity – rare side effect
• Has black box warning for suicidality.
WHEN TO CONSIDER STRATTERA
 History of adverse effect to stimulants
 Comorbid anxiety, depression, tics, enuresis or Tourette’s
 Require 24 hour symptom relief
 Severe stimulant rebound
 Personal or family history of substance abuse
 Concern about insomnia or appetite suppression

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APPROACH TO TREATMENT
A P P ROAC H TO T R E AT M E N T
D I AG N O S T I C T H E O RY
• Developmental Context, Environment Diagnostic
Theory
• Diagnosis

Monitor Treatment
Developmental Response Targets
Context &
Environment

Diagnostic
Theory
Intervention

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GENERAL DIFFERENTIAL
Developmental/ Emotional/ Physical/Other
Learning Behavioral

Difficulty with Intellectual Avoidance/Worry Snoring, Awakening, or

functioning/adaptive difficulty with sleep
functioning

Difficulty with Acquisition and Episodic periods of mood Substance Use

use of language
Are there deficits in developing Pattern of negativistic, hostile, Tics
and understanding defiant, or antisocial behaviors
relationships; deficits in social-
emotional reciprocity; and
restricted repetitive patterns
Difficulty with Learning Recent(or other) Trauma Other psychiatric or medical
history
REBECCA
• Rebecca is a 10 year-old girl who had been struggling with ADHD
symptoms of inattention for years. She was started on Concerta and
is currently taking 36 mg/day with improvement in school
performance. She has been tolerating the medication well and has
been thriving in 5th grade.
REBECCA
• Rebecca’s mother brings her in for a sick visit, noting that for
the past 2 weeks, Rebecca “has developed asthma and her
ADHD is worse.” She has been coughing persistently and
occasionally shaking her head violently, and the teacher
complained about her behavior disrupting class. She has no
significant PMH, no other medications. Mother is very
concerned about these episodes, which do not happen while
she sleeps. Rebecca does not report being bothered by these
behaviors, which “I just kind of have to do.”
WHAT HAPPENED TO REBECCA?
D I AG N O S T I C T H E O RY A P P ROAC H TO T R E AT M E N T

• Developmental Context, Environment Diagnostic

• Diagnosis Theory

Developmental
Context &
Environment
Monitor Treatment
Response Targets

Diagnostic
Theory

Intervention

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GENERAL DIFFERENTIAL
Developmental/ Emotional/ Physical/Other
Learning Behavioral

Difficulty with Intellectual Avoidance/Worry Snoring, Awakening, or

functioning/adaptive difficulty with sleep
functioning

Difficulty with Acquisition and Episodic periods of mood Substance Use

use of language
Are there deficits in developing Pattern of negativistic, hostile, Tics
and understanding defiant, or antisocial behaviors
relationships; deficits in social-
emotional reciprocity; and
restricted repetitive patterns
Difficulty with Learning Recent(or other) Trauma Other psychiatric or medical
history
REBECCA
• Initial Diagnosis – ADHD Diagnostic
Theory
• Initial Treatment Targets –
Improve attention at school
and decrease hyperactive Monitor Treatment
Response Targets
behavior
• Intervention – Concerta 36mg
• Response - Vanderbilts
Intervention
follow-ups showed improved
attention, school performance
has also improved
WHAT TO DO FOR REBECCA?
• Get more information and talk to family in the office
– Review initial diagnosis and treatment targets
• What did they mean by hyperactive behavior?
• Is inattention really ADHD?
– Review intervention and response
• How impairing is the “coughing and shaking”
– Reconsider diagnostic theory
• Throat clearing in the past?
TIC DISORDERS
• Up to 65% of children initiating Rx with MPH may develop a
transient tic
– Simple Motor, Complex Motor, or Vocal
• Stimulants may cause or “unmask” tics

• Treatment: Alteration in stimulant dose, discontinuation of

stimulant, change of stimulant, α-2 agonists, antipsychotics,
CBT, Strattera
REBECCA
• Review initial diagnosis, treatment targets and
response
–Initial Vanderbilts
• Inattention - 6/9 total = 15,
• Hyperactivity – 2/9 total = 7
–What did they mean by hyperactive behavior?
• Fidgeting, and moving when not supposed to
move.
–Is Inattention actually ADHD?
WHAT HAPPENED TO REBECCA
S H E H A S D E V E LO P E D T I C S S H E H A S A LWAYS H A D T I C S

• ADHD and Tic Disorders are related. (brain structure overlap

and pharmacologically)
– Kids with ADHD have higher rate of tic disorders
– Kids with Tic Disorders have a higher rate of ADHD
• AACAP recommendations – treat whichever is most
impairing first
– My recommendations ** beware that treatment target
actually lines up with the diagnosis you are treating first
**
SO YOU THINK SHE HAS TICS

•How impairing is the “coughing and

shaking”
•Are there any other potential tics
•Did it ever happen before?
–Throat clearing in the past?
REBECCA TREATMENT TARGET
• Clarify treatment targets
– The “hyperactive behavior” could have been tics to begin
with – so you shouldn’t expect to treat that with stimulants
• Hyperactivity is not a good initial treatment target
– You should still monitor as potential side effect of
stimulant
– Could be a treatment target if you are doing evidenc-
based nonpharmacologic intervention for this
behavior
– Is inattention a symptoms of ADHD(or something else?)
REBECCA DIAGNOSIS

• Review her ADHD symptoms – she has trouble

completing 3 step commands, head in the clouds, room is
a complete mess and mom says she’s just like dad who
has ADHD and does really well on a stimulant.
• Don’t forget about the potential of anxiety and transient
tic.

• I think she does have ADHD

REBECCA MEDICATION MANAGEMENT

• Options
– Reduce stimulant to 27mg and follow-up
• If this is not effective add Tenex or Intuniv ER
– Add Tenex or Intuniv ER and follow-up
KURTIS
• Kurt is an 8 year old boy with ADHD and ODD. He has home-based therapy. There is
no history of trauma. He does not have any anxiety, depression, conduct disorder, or
other medical condition. He has friends. Teachers express frustration with him because
he seems to argue a lot, and purposely defy rules.

• Mom brought him in today stating that school is going much better this year now that
he is taking Adderall XR 20mg for 6 month, but that he is angry, irritable, postures
aggressively to her in the afternoons. He is even irritable in the afternoon on the
weekends when there is no school work.
WHAT HAPPENED TO KURT?

D I AG N O S T I C T H E O RY A P P ROAC H TO T R E AT M E N T

• Developmental Context, Environment Diagnostic

• Diagnosis Theory

Developmental
Context &
Environment
Monitor Treatment
Response Targets

Diagnostic
Theory

Intervention

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WHAT SHOULD YOU DO ABOUT
KURT’S IRRITABILITY
• Review diagnosis and treatment targets
– Vanbderbilts confirm that school really is going well. Although a number of domains on the
Vanderbilts are scored at 1/2, none are significant anymore
– Teachers report that they have made accomodations to reduce work burden. Mom confirms
that these have helped
• Diagnostic theory – still ADHD, and afternoon irritability with mom a component of
ADHD

• New treatment target – starting homework without having aggressive behavior

towards mom 3/5 days of the week instead of 0/5 days a week(home based team could
clarify goal for family)
GENERAL DIFFERENTIAL
Developmental/ Emotional/ Physical/Other
Learning Behavioral

Difficulty with Intellectual Avoidance/Worry Snoring, Awakening, or

functioning/adaptive difficulty with sleep
functioning

Difficulty with Acquisition and Episodic periods of mood Substance Use

use of language
Are there deficits in developing Pattern of negativistic, hostile, Tics
and understanding defiant, or antisocial behaviors
relationships; deficits in social-
emotional reciprocity; and
restricted repetitive patterns
Difficulty with Learning Recent(or other) Trauma Other psychiatric or medical
history
GOAL “DECREASE IRRITABILITY IN
THE AFTERNOON”
• Options – treat ADHD in the afternoon with a stimulant
or alpha agonist

• Alpha agonist – tenex 0.5mg – could start at bedtime

for at least three days so he adapts to sedation effect(if
he has it)
–Once he has adapted give the medication ½ hour
before he starts to develop afternoon symptoms
GUIDANCE AND
ANTICIPATORY
GUIDANCE
ADOLESCENT

• I’m worried about my girl’s hygiene. • Should I consider an afternoon dose?

– This is a common complaint from • YES

mother’s of girls with ADHD
– Does the adolescent have more
afternoon school work
– Warning mothers about this and the – Will the adoelescent be driving soon
importance to scaffold this skill as they
– Will the adolescent be working in the
would scaffold other skills
evening?

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ADOLESCENT
• Be aware of “burn-out effect”
– Tendency of parents/family to feel that the child is “ready” to
take on responsibility and as a result give all responsibility to
the child at once

• PLAN
– Let parents know that they will need to have some
responsibility for monitoring their child’s medication
throughout adolescence
– Changes in monitoring and support should come in baby steps
– Consider switching parent who does homework, trying other 56

methods to help with homework

MY 13 YEAR OLD GIRL HAS GROWN A
LOT AND HER INATTENTION IS BACK.
• Should the medication be • Will you send me a higher
increased because of her dose of medication?
change in weight?
• Has an evaluation been done
• NO this year suggestive of ADHD
• YES – increase medication
• NO – get vanderbilts,
consider PHQa and SCARED

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ADOLESCENT
• My child doesn’t like the way
• My 14 year old son is now
the medication makes her
fighting me each time we sit
feel.
down to homework
• PLAN
• PLAN
– Can child “pair up” with a
– Bring child in to assess
responsible friend?
what positives there are –
– Consider changing the
and capitalize on them.
parent that manages
homework.
– Consider tutoring.
– Add afternoon medication
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LATE HIGH SCHOOL/GRADUATION
• I don’t think my child is ready for college/military/etc as (s)he has
trouble taking care of everyday needs

• Remember the importance of small steps

– Start the steps early
– Start with job early
– Consider a “year off” between high school and next step
• Get a job
• Manage bills
• Pay for housing, etc

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GOING TO COLLEGE
• Consider getting support in college
– Studying support
– Therapy support
• Put that child in charge of finding out what’s available on campus.
• Seriously consider whether or not the adolescent can manage
stimulants on campus.
• Make sure there is a way to secure medications in the dorm room.
• Talk about the importance of sleep, eating, etc
• Sharing medication is illegal

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HOW SHOULD MY CHILD USE
MELATONIN?
• Has been shown to be useful for delayed sleep
• Also useful with ADHD and sleeping problems
– Weight < 40kg up to 3mg
– Weight >= 40 kg up to 6mg

• Can be used from late evening/dinner to ½ hour before

sleep
TAKE HOME POINTS
• Comorbidity is the RULE with ADHD
• Inattention ≠≠ Attention Deficit/Hyperactivity Disorder
– In other words– ADHD is never just one symptom
• Improved med management may impact comorbidities
• Non-pharmacologic intervention has a vital role
• ADHD is a lifelong condition – with serious lifelong implications

• A consistent approach(with follow-up) can make the difference

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THANK-YOU