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ADHD RESEARCH UPDATE - Vol. 21, July, 1999
******************************************************************In this issue...
* Medication treatment for child and adolescent psychiatric disorders:
What is the evidence?* ADHD in other cultures: The prevalence of ADHD among Brazilian
adolescents* Diet and ADHD revisited
* Differentiating ADHD from Pervasive Developmental Disorder
- Subscriber Question -
"My child's physician started him on 5 mg. of Ritalin recently. It didn't seem
to be working and my son was complaining of headaches so the doctor switched
him to imiprimine. He told me that this was an antidepressant that also helps
children with ADHD. Is this a good thing to try?"
____________________________________________________________
* MEDICATION TREATMENT FOR CHILD AND ADOLESCENT
PSYCHIATRIC DISORDERS: WHAT IS THE EVIDENCE?There was a very important paper that appeared in the May, 1999 issue
of the Journal of the American Academy of Child and Adolescent Psychiatry
on the use of medication for treating psychiatric disorders in children and
adolescents (Jensen, P.J., Bhatara, V.S., Vitiello, B., Hoagwood, K., Feil,
M., & Burke, L.B. (1999). Psychoactive medication prescribing practices
for U.S. children: Gaps between research and clinical practice). In this
paper, the authors examine the frequency with which different
medications are prescribed in relation to what research data exists for
the safety and efficacy of the different meds. Although this encompasses
disorders other than ADHD, I think this is quite an interesting and important
paper to include in ADHD RESEARCH UPDATE. This is because I know
that many of you have children who receive medications other than
stimulants, and knowing something about the research support for these
medications would be important. In addition, many professionals who
receive the newsletter may be involved in prescribing these medications to
the children they treat.There are 8 classes of medications that were looked at in this paper. Each
class of medication, examples of brand name meds from each class, and the
type of disorder it is typically prescribed for are presented in the table below.
(Note: The medications listed in the Selected Examples column are just examples
of medications from the general category.)Category Selected Examples Problem prescribed for
Stimulants Ritalin, Adderall ADHD
SSRIs (Selective Fluoxetine (Prozac) Major Depression
serotonin reuptake sertraline Obsessive compulsive
inhibitors) disorder (OCD)
Anxiety disordersCentral adrenergic Clonodine Tourette's disorder
agonists guanafacine ADHD
Anticonvulsant mood Valproate and Bipolar disorder
stabilizers carbamazepineTCAs (tricyclic Elavil Major depression
antidepressants) imiprimine ADHDBenzodiazepines alprazolam Anxiety disorders
clonazepanAntipsychotics Risperidone Childhood schizophrenia
Haloperidal Tourette's disorder
Clozapine
Lithium Bipolar disorder
Aggression
In terms of the frequency with which these different classes of medication are prescribed,
the numbers differed somewhat depending on which national data base the estimates are
based on. Not surprisingly, stimulant medications are far and away the most frequently
prescribed medication in child psychiatry. The best estimates available are that stimulant
medications were prescribed in nearly 2 million visits for patients under the age of
18 during 1995. This is between 5 and 10 times the next most-frequently prescribed class
of medications, the SSRIs. Even the least-frequently prescribed medication in this
listing was estimated to have been dispensed to thousands of children, however.One clear conclusion made by the authors is that it is really quite difficult to obtain accurate
estimates of just how often psychoactive medications are being prescribed to children and teens
in this country. In fact, the best data that exists is probably on the prescription of stimulant
medications for ADHD. Clearly, having more accurate data on the use of such medication
for children and teens would be very useful to have.What about the evidence supporting the efficacy and safety for the use of such medications in
youth? The authors examine this in relation to what is known about both short- and long-
term efficacy, and short- and long-term safety. The grading scale they used, and the criteria
for the different grades are shown below:Efficacy Ratings
A - Efficacy supported in at least 2 or more randomized, controlled trials. These would be
studies in which children's response to medication was compared to how they responded
to a placebo;B - Efficacy supported in at least 1 randomized controlled trial;
C - Efficacy supported by "informed" clinical opinion, case reports, or non-placebo controlled
trials. This would generally be considered only an initial stage in documenting the efficacy
of a pharmacologic treatment;Safety Ratings
A - Low incidence of adverse event reports to the FDA. That is, adverse effects that could
be attributed to the medication have been infrequently reported.Note: This is not the same as having safety data established based on long-term randomized
and controlled clinical trials. As the authors note, however, conducting such trials for
for long-term safety data may be neither ethical nor feasible.B - Clinically significant adverse event reports restricted to case reports and/or anecdotal reports,
suggesting possible rare side effects.C - No data or minimal data supporting long-term adversity or safety. In other words, little about
the long-term impacts are really know, one way or the other.
Using these criterion, the grades assigned by the authors based on their review of the literature
are shown below. The conditions under the general class of medicaqtion indicate the disorder
for which the ratings in that row apply. For example, stimulant medications for treating ADHD
receive grades of A and B for short- and long-term efficacy respectively, and grades of A for
short- and long-term safety. As you can see, when the same type of medication is used to treat
different conditions, and the grades are not always the same. (Sorry, but I was not able to get
things to line up exactly.)
Category Short-term E. Long-term E Short-term S Long-term S
Stimulants
for ADHD A B A A
SSRIs
for major dep. B C A C
for OCD A C A C
for other anxiety C C C C
disorders
Central adrenergic
agonistsfor Tourettes B C B B
for ADHD C C C CValproate and
carbamazepinefor bipolar disorder C C A A
Tricyclics
for major depression C C B B
for ADHD B C B BBenzodiazepines
for anxiety disorders C C C C
Antipsychotics
for schizophrenia B C B C
for Tourettes A C B BLithium
for bipolar disorder B C B C
for aggression B C C C
Please note that these grades are based on the authors' review, and other experts in the field
might conceivably come to somewhat different conclusions. Overall, however, the ratings
indicate important gaps in current knowledge. As you can see, not a single of the most frequently
used medications for treating child and adolescent disorders received grades of A across the
board. Stimulant medications for treating ADHD came closest, and I think that soon-to-be-published
studies on long-term efficacy will turn this into an A grade quite shortly. In contrast, the long-term
efficacy grade for every other medication was a C. Remember, this does not mean that these
compounds are not effective for the designated use. Instead, it means that solid scientific data that
documents long-term efficacy is not yet available. Practitioners are using these meds based on
clinical opinion, case reports, and uncontrolled trials. Even when it comes to short-term efficacy,
only two other classes of medication received A grades for treating a particular disorder.There are several important points that can be taken from this excellent review paper. First, one
could certainly make a case that these medications are being over prescribed, given the efficacy
and safety data that is available to support their use. For example, given the frequency with
which antidepressant medications are prescribed for children and teens, the relative lack of
scientific support for this is quite surprising. To date, there has been but a single study in which
an antidepressant produced significantly better effects than a placebo in younger depressed patients
(this was for fluoxetine - the generic form of Prozac - and where the results were 56% improved on
fluoxetine vs. 33% on placebo). Clearly, there is a pressing need for more scientific study of these
medications for treating children and teens.Second, when one looks at the data above, it is surprising how much controversy there continues
to be about the use of stimulant medications for treating ADHD relative to the use of the other
medications listed. Clearly, stimulant medications have the best established efficacy and safety
data available, even though more work in this area is also called for. If as much supportive data
was available for these other medications as is currently available for stimulants, however, we
would be much further along in our knowledge than we currently are.Finally, I think these data suggest that one should be cautious about using medications to
treat most psychiatric conditions in children and teens. With certain exceptions, the data to
support the use of medications is not so compelling that one would not want to carefully
explore other treatment options.The authors - 3 of whom are child psychiatrists heavily involved in research - close their
paper with the following statement:"The lack of safety and efficacy data for psychotropic medications is of general concern,
not just for parents of children with mental illness and their physicians, but for all with
a stake in the future of the nation's children."They lay out a set of recommendations for helping to close these important gaps in knowledge
that will hopefully be heeded by researchers and pharmaceutical companies in the years
ahead.
* ADHD IN OTHER CULTURES: THE PREVALENCE OF ADHD AMONG BRAZILIAN
ADOLESCENTSIt is still reasonably common to hear people express doubts about the validity of ADHD as
a "real" disorder because they argue it is largely an "United States phenomenon". The idea is
that ADHD is more or less an invention of our own particular culture, and that it is not nearly
so commonplace in other cultures. A study published in the June issue of the American
Academy of Child and Adolescent Psychiatry provides additional evidence against this
point of view (Rohde. L.A., et al; (1999). ADHD in a school sample of Brazilian
Adolescents: A study of prevalence, comorbid conditions, and impairments. Journal of
the American Academy of Child and Adolescent Psychiatry, 38, 716-722.)In this study, the authors began by screening over 1000 students between the ages of 12 and
14 for ADHD. The screening procedure used student's own reports about the number of
ADHD symptoms that they experienced. (I think that self-reports were used but this was not
entirely clear to me.) Those whose responses to the screening questionnaire suggested
a high likelihood of ADHD were then asked to participate in a much more extensive
clinical assessment to determine whether the diagnosis applied. In addition, a random group
of students whose responses were not suggestive of ADHD were also asked to participate in the
more extensive clinical assessment. This was done to ensure that the psychiatric researchers
conducting the clinical assessments would not be biased by the knowledge that the student
they were evaluating was likely to have ADHD. The clinical assessment included interviews
with the student and parents, along with the collection of standardized behavioral data from
both parents and teachers.The primary finding from this study was that almost 6% (5.8% to be exact) were diagnosed
as having ADHD based on the extensive clinical assessment. This rate was based on the
% of students who had screened positive who were diagnosed with ADHD based on the
extensive assessment and the percentage who were screened "negative" but who were
given the diagnosis based on the more comprehensive assessment. This prevalence rate is
consistent with what has been reported for the prevalence rate of ADHD in the United
States. Thus, when careful procedures were used to estimate the prevalence of ADHD
in a culture quite different from our own, using the same diagnostic criteria, similar
estimates were found. This is certainly inconsistent with the notion that ADHD, is to a
considerable extent, an "invention" of American medicine. Also similar to what has been
reported in other studies was the proportion of the different ADHD subtypes, which were
52.2% for the combined type (i.e. both inattentive and hyperactive/impulsive symptoms),
34.8% for the inattentive subtype, and 13.3% for the hyperactive/impulsive subtype.As has been reported in samples of US children, high rates of co-occurring behavioral
disorders were also found. Thus, 26.1% of the children diagnosed with ADHD also
qualified for the diagnosis of Conduct Disorder, and another 21.7% qualified for the
diagnosis of Oppositional Defiant Disorder. Collectively, almost 50% of the ADHD
sample was thus diagnosed with a co-occurring behavioral disorder. This again
underscores how frequently these important behavioral problems develop in children
with ADHD, and how parents need to be vigilant in making sure that these difficulties
are also being specifically addressed in their child's treatment. Remember, the long-
term outcomes for children with ADHD who also have significant behavior problems
is much poorer than for children who have ADHD alone.On the positive side, there were no significant differences found in the rates of
substance use between teens with and without ADHD. Teens with ADHD, however,
were more likely to be smokers (17% vs. 5%). Given the adverse health consequences
associated with smoking, parents of children with ADHD may need to be especially
vigilant about addressing this issue with their child.There was one surprising finding that is worth noting. In this sample, the rates of ADHD
among males and females was almost identical. This is very different from what has
been reported in other studies, where ADHD is found to be as much as 4 times more
common in boys. One possibility is that this study focused exclusively on teens rather
than school-age children, and there has been recent speculation that ADHD may be a
more persistent disorder in females than in males. In other words, even though males
may be more likely to have ADHD in earlier childhood than females, some researchers
have suggested that the symptoms of ADHD are more likely to persist among girls with
the disorder. If so, the rates of ADHD for males and females would be closer during
the teen years. This is an interesting hypothesis, but is certainly one that requires
additional research.
* DIET AND ADHD REVISITED
What is the evidence to support the effectiveness of dietary interventions for treating
ADHD? This has been a source of ongoing controversy. Advocates
of dietary interventions report that this can be a helpful approach for many
childrenwith ADHD. The consensus within the mental health community, however, has
been much less supportive. This has ranged from the belief that dietary changes are not
helpful at all, to this intervention approach may help a small minority of ADHD children.This issue is addressed in a paper by Dr. Eugene Arnold that appeared in the
Journal of Attention Disorders (Arnold, L.E. (1999) Treatment alternatives for
ADHD. Journal of Attention Disorders, 3, 48). In this extensive paper, Dr.
Arnold reviews a host of alternative treatment approaches in regards to their
current scientific status. (Note: I reviewed a presentation he gave on this work
at the recent NIH Consensus Conference on ADHD in Volume 14 of ADHD
RESEARCH UPDATE). Here, however, I want to focus on his detailed review
of dietary interventions.Dr. Arnold notes that since 1982, at least 8 controlled studies of the link between
dietary factors and ADHD symptoms in children have been conducted that use
adequate scientific methodologies. These studies have all demonstrated either significant
improvement in children's behavior compared to a placebo condition when certain
foods are removed from a child's diet, or, the significant deterioration in children's'
behavior when the offending substances are introduced. According to Dr. Arnold, a
typical diet associated with improvement in ADHD symptoms might exclude everything
except the following: lamb, chicken, potatoes, rice, bananas, apples, cucumbers, celery,
carrots, parsnip, cabbage, cauliflower, broccoli, salt, pepper, vitamins, and calcium.The conclusion reached by Dr. Arnold is that the efficacy of dietary interventions
for some children with ADHD has been convincingly demonstrated. The main
scientific task at this point, he feels, is to determine what percentage of
children with ADHD this approach is helpful for. Apparently, when children with
ADHD are screened specifically to include those who are suspected of having
food sensitivities, half or more seem to respond well under controlled conditions.
Thus, for a child with ADHD and demonstrated food sensitivities, dietary interventions
may have a reasonably good chance of being helpful. What proportion of the general
population of children with ADHD this represents is unknown, however. In addition,
even for children who are helped by dietary changes, llittle is known about any
long-term benefits associated with this treatment approach.There would not seem to be any significant risks associated with this approach.
Some have questioned whether such restrictive diets provide children with
sufficient nutrient intake while others suggest that eliminating junk food improves
essential nutrient intake. Some professionals have also voiced concerns about the
conflict that may arise from placing children on such a restricted diet. Then again,
this would not seem to necessarily have to be any worse or more common than the
conflicts that can emerge over taking medication. In both cases, addressing these
challenges in a thoughtful manner would be required.Overall, Dr. Arnold suggests the greatest risk may be the delay of more effective
treatment if the child is a non-responder. Like any treatment approach - including
medication - you would need to carefully monitor how the treatment is effecting
your child in multiple domains (i.e. behavior, academics, social relations) and to
make changes and adjustments - including abandoning the approach - if it does not
seem to be providing adequate results after a fair trial.I find this work to be quite interesting. If you are a parent who wants
to consider this approach for your child, it would be important to try and find someone
who really knows what they are doing in this regard. For example, I know that
advising parents on how to implement this approach would certainly
not be something that I was qualified to do. I'll keep my eyes open for more
work in this interesting area and will include it in the newsletter as I come
across it.
* DIFFERENTIATING BETWEEN ADHD AND PERVASIVE DEVELOPMENTAL
DISORDER (PDD)One factor that often complicates the accurate diagnosis of ADHD is the need to rule
out other conditions as a better explanation for the child's symptoms. For example,
children with mood disorders, anxiety disorders, or learning disabilities can sometimes
display a pattern of symptoms that resemble ADHD. Diagnostic errors can occur unless
a careful evaluation to rule out these alternative explanations for a child's symptoms has
been made.In young children especially, pervasive developmental disorders can sometimes be
confused with ADHD. The category of pervasive developmental disorders includes
several different diagnoses including autism, Asberger's Syndrome, and a residual
category labeled Pervasive Developmental Disorder - NOS (i.e. not otherwise
specified). The latter is reserved for children whose symptoms do not fully match
the more specific diagnoses in this category, and is generally associated with less
severe impairment than the other diagnoses in this group. Distinguishing children
with ADHD from high-functioning children with PDD-NOS is probably one of the
most difficult differential diagnoses to make. As a result, a number of children with
PDD-NOS may be misdiagnosed with ADHD and treated inappropriately as a result.The authors of a study appearing in a recent issue of the Journal of Learning Disabilities
attempt to provide a set of research based guidelines to help with this difficult and
important distinction (Roeyers, H., Keymeulen, H., & Buysee, A. (1998). Differentiating
ADHD from Pervasive Developmental Disorder Not Otherwise Specified. Journal of
Learning Disabilities, 31, 565-571.) In this study, 27 children with ADHD were matched
with 27 children diagnosed with PDD-NOS on both chronological age and IQ. These
children had been diagnosed with PDD-NOS or ADHD based on an extensive and rigorous
diagnostic evaluation.The parents of these children were then interviewed to learn about any pregnancy and/or
birth complications, and were also asked to provide detailed information about their
child's development between birth and age 4. The goal was to identify factors that reliably
distinguished between children in the two groups in the hope that this would aid clinicians
involved in making this differential diagnosis. The results can also be helpful to parents who
may have concerns about whether the diagnosis of PDD-NOS may apply to their child.An extensive questionnaire was developed by the authors for parents to complete. The
first part of the questionnaire included items asking about pregnancy and birth complications.
The second portion included over 100 items that asked about a child's functioning in
12 broad areas including feeding, sleeping, toilet training, activity level, communication,
motor development, social development, social behavior, information processing,
behavior problems, play, stereotypic (i.e. unusually repetitive) behaviors, and
anxiety. Parents were asked to rate whether or not a specific problem applied
to their child in 6 different age periods: 0-3 months, 4-6 months, 7-12 months,
13-24 months, 25-36 months, and 37-48 months. They were also asked when they first
suspected that something was wrong with their child, and at what age their child received
his or her final diagnosis. The main results of this interesting and important study are
summarized below.PREGNANCY AND BIRTH COMPLICATIONS
There were no significant differences in pregnancy complications between the
two groups. Overall, about 25% of mothers reported problems during pregnancy.
A significantly larger percentage of children with ADHD were reported to have
exhibited "extremely loud" crying immediately after birth (32% vs. 9%).0-3 MONTHS
Virtually no differences between children in the 2 groups were reported by parents
for the first 3 months of life.4-6 MONTHS
During this period, parents of children with PDD-NOS reported that their child had
shown significantly more behavior problems than were reported by parents of children
with ADHD. The single item responsible for this difference was that children
with PDD-NOS were more likely to be described as having been unresponsive to
social stimulation (63% vs. 20%). In other words, these children were recalled by
their parents as having been more difficult to engage and interact with, and to be more
in their "own world".7-12 MONTHS
Children with ADHD were reported to show more hyperactive behavior during this
period than children later diagnosed with PDD-NOS. Children with PDD-NOS
continued to be seen as less responsive to social stimulation.13-24 MONTHS
Children with ADHD were recalled as displaying more "reckless" behavior during
this period. Children with PDD-NOS continued to be seen as less responsive to
social stimulation. In addition, their parents were more likely to report that their
child had displayed motor tics and indications of excessive anxiety. The parents
of children with PDD-NOS also recalled that their child experienced difficulty
understanding gestures and emotions, and did not show any symbolic play (i.e. pretend
or make-believe play). It should be noted that although children with ADHD were
described as more "reckless", differences in overall activity level between the 2 groups
was no longer significant. Thus, differences in "hyperactivity" between the groups seemed
to disappear after the first year as children with PDD became increasingly active.This is important because it implies that in older children, one can not rely on
hyperactivity alone - one of the core symptoms of ADHD - to differentiate between
children with ADHD and children with PDD-NOS.25-36 MONTHS
Children with ADHD continue to be recalled as having been more reckless.
Children with PDD-NOS continue to be recalled as less responsive, less able
to understand emotions and symbolic gestures (e.g. facial expressions), more
likely to show motor tics, and more anxious. In addition, parents of children
with PDD were more likely to report that their child was experiencing difficulty
with peer relations during this period (89% vs. 42%).37-48 MONTHS
The two groups continued to differ on the factors described for the 25-36
month period.OTHER DIFFERENCES
In addition to the differences noted above, parents of children with PDD-NOS
reported being aware earlier on that something was wrong with their child. Among
the parents in this study, the mean age at which they first became concerned about their
child's development was 13 months. For parents of children with ADHD, in contrast,
the average age was 38 months - more than 2 full years later.Parents of children with PDD-NOS also experienced more difficulty in the
evaluation and diagnostic process. On average, children with PDD-NOS were
not diagnosed until an average of 48 months from when they first reported concerns
to a health care professional. For children with ADHD, an average of 20 months
elapsed between parents' initial report of concerns and the final diagnosis.CONCLUSIONS AND IMPLICATIONS
This interesting and important exploratory study suggests that among very young
children and older preschoolers, the most consistent factors to differentiate children
with ADHD from children with PDD-NOS is that children with ADHD engage in
more reckless behavior. Children with PDD-NOS, in contrast, are more likely to
appear socially unresponsive, to experience difficulty in understanding emotions
and symbolic gestures, and to display motor tics and high levels of anxiety. After
the first year of life, differences in activity level may not be found.Misdiagnosing a child with ADHD when he or she really has PDD-NOS can
have important negative clinical implications. Stimulant medication is more
likely to be effective in children with ADHD, and it may even exacerbate
symptoms in children with PDD. Non-medical approaches will also often
be different for children with these diagnoses. For a child with PDD, it is generally
believed that effective treatment requires high parental involvement, a
structured approach characterized by high predictability in the environment for
the child, and a focus on the development of basic socialization skills (e.g. getting
and staying engaged with others, being able to take part in reciprocal interactions),
communication training, and the generalization of these skills so that the
child can apply them with different people. Note that the primary focus is on helping
the child to develop the basic building blocks for effective interpersonal relating -
i.e., being able to tune in to others in a more sustained and consistent way.For preschool children with ADHD, there is typically a greater focus on helping
parents learn child management techniques, providing a structured preschool
environment where there are clearly established rules and consequences,
helping children develop self-control, and, medication if the child's symptoms are too
difficult to manage after behavioral measures have been implemented. The focus
on basic engagement and reciprocal interaction skills would generally not be needed.
Thus, a child who really has PDD-NOS rather than ADHD would not be likely to get
the help he or she needs in this crucial area. Also, because PDD-NOS is likely to
be associated with more significant and ongoing impairment in social relations, parents
of a child who is misdiagnosed may have unrealistic expectations for how their child will
respond to treatment.I think this is an important study in that it provides a timely reminder about
early aspects of a child's social development that need to be considered in
a thorough evaluation for ADHD. If you are a parent of a child who has
been diagnosed with ADHD, and have concerns/questions about whether
PDD-NOS may be a more accurate diagnosis for your child's problems, than
it would REALLY be important to consult with an experienced child mental health
professional or a developmental pediatrician. I would suggest consulting
with a professional who has extensive experience in children's early social
and emotional development, and who has worked with children who have
pervasive developmental disorders. Such a professional is most likely to be
able to provide you with the information and answers you need to know about
how to best help your child.
- Subscriber Question -
"My child's physician started him on 5 mg. of Ritalin recently. It didn't seem
to be working and my son was complaining of headaches so the doctor switched
him to imiprimine. He told me that this was an antidepressant that also helps
children with ADHD. Is this a good thing to try?"I would suggest that you discuss this change with your child's physician. There
are several reasons why I think this is important to do. First, a 5 mg dose of
Ritalin is a very low dose and it is quite possible that your son would have
shown a positive response to a higher dose if this were tried. If the reason
for switching was because of the headaches your son complained of, it
is important to be aware that this side effect can dissipate after a short
time for many children. Also, you should remember that what appears to
be a side effect of the medication may actually have been a placebo effect.
Several studies have shown that children often complain of such things, or parents
believe they are observing adverse effects of medication, when the child is
actually receiving a placebo. Now, it might really be the case that your child can
not tolerate Ritalin because of adverse effects like headaches, but I would be
reluctant to conclude this based solely on the information you describe.Even if an additional trial of Ritalin was not helpful, or continued to produce
headaches for your son, I would still wonder about the immediate switch to an
antidepressant. A number of studies have shown that when a child does not
respond to the first stimulant that is tried, there is still a reasonable chance that
they will respond to a different stimulant medication. For example, if your
child is not helped by Ritalin, he might still respond positively to a medication
like Dexedrine or Adderall, and might do so without experiencing any adverse
side effects. In a recently completed large scale intervention study of ADHD,
children receiving medication would typically receive an extended trial of several
types of stimulants before switching to a completely different class of medication.Although there have been studies indicating that antidepressants such as imiprimine
can be helpful for children with ADHD, overall, the evidence to support the use of
stimulant medications is greater. This is true in terms of both efficacy data and safety
data. Your physician may certainly have good reasons for recommending this switch,
but I would want to get his or her opinion on the points discussed above.That's all for this month...
I hope you enjoyed this issue of ADHD RESEARCH UPDATE and found it to
be informative.Please feel free to share information in this newsletter with others you know who
may be interested in it. If you know someone who would like to receive this
information on a regular basis, however, please suggest that they get in touch
with me about subscribing. My e-mail address is addhelp@mindspring.com.
In appreciation for your referral, I will extend your own subscription by 4
additional months.If you manage a web site related to ADHD, and would like to include information
from this issue on your site, please feel free to do so. I would be delighted for you
to select an article from the newsletter to post. Please include a link to
my site so that people who would like to learn more about the newsletter are
able to do so. My address is www.helpforadd.com.I hope your doing well.
Sincerely,
David Rabiner, Ph.D.
Licensed Psychologistcopyright David Rabiner, PhD and ADHD RESEARCH UPDATE, 1999