Attention Deficit/Hyperactivity Disorders (ADHD) Research Paper

This sample Attention Deficit/Hyperactivity Disorders (ADHD) Research Paper is published for educational and informational purposes only. Free research papers are not written by our writers, they are contributed by users, so we are not responsible for the content of this free sample paper. If you want to buy a high quality research paper on any topic at affordable price please use custom research paper writing services.

Abstract

Attention deficit/hyperactivity disorder (ADHD) is a psychiatric disorder affecting 3 to 5% of children. Recent data suggest that the incidence of ADHD may be even higher (5–7%). ADHD is a chronic disorder, with approximately 75 to 80% of affected individuals showing evidence of significant impairment during adolescence and adulthood. Estimates suggest that 1.5 to 2.0% of adults and 2 to 6% of adolescents have ADHD. Research indicates that children with persistent ADHD have more severe symptoms, significant impairment in functioning, stressful family environments, and more adverse risk factors. There are a number of factors that interact with ADHD and further compromise adjustment over the life span.

Outline

Core Characteristics of Attention Deficit/Hyperactivity Disorder
Associated Problems
ADHD with Other Disorders
Gender and Cultural Issues
Etiology of ADHD
Developmental Context for ADHD
Evidence-Based Interventions for ADHD
Medication Monitoring and Adherence
Risk and Resiliency Factors that Affect ADHD

1. Core Characteristics Of Attention Deficit/ Hyperactivity Disorder

Core symptoms of inattention, impulsivity, and hyperactivity comprise the major characteristics of attention deficit/hyperactivity disorder (ADHD), with new conceptualizations emphasizing poor self-control and behavioral disinhibition. Behavioral disinhibition is synonymous with poor self-regulation or the inability to control one’s activity level, attention, and emotions. In 1997, Barkley posited that disinhibition interferes with executive control functions, including working memory, internalization of speech to guide one’s behavior, motor control for goal-directed behavior, the ability to analyze and synthesize responses, and self-regulation of emotions, motivation, and arousal.

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) outlined three subtypes of ADHD: attention deficit disorder/predominantly inattentive type (ADD/PI), attention deficit disorder/predominantly hyperactive-impulsive type (ADD/PHI), and attention deficit disorder/combined type (ADD/C). Inattention is multifaceted and refers to difficulties with distractibility, alertness, and arousal as well as with selective, sustained, and persistent attention to tasks. Individuals with ADD/PI appear to have cognitive disabilities (e.g., spacey, ‘‘daydreamy,’’ sluggish, easily confused) that arise from slow information processing and poor focused/selective attention. There is some debate in the literature as to whether ADD/PI is a separate disorder distinct from ADD/PHI or ADD/C. Further research is warranted on this issue, particularly as it relates to gender differences. For example, some studies report that girls have higher rates of inattention than of impulsivity and hyperactivity.

Impulsivity encompasses the inability to inhibit behavior, delay responding, and delay gratification to reach long-term goals and perform tasks. Hyperactivity is one of the more obvious core features of the disorder and refers to excessive activity (both verbal and physical). Individuals with ADD/PHI display primary problems with hyperactivity and impulsivity, whereas those with ADD/C show deficits in all core symptoms, including impulsivity, inattention, and hyperactivity.

2. Associated Problems

The core symptoms of ADHD lead to impairment in all aspects of life activities, including school attainment, family adjustment, social relations, occupational functioning, and self-sufficiency. Sleep disorders, health problems (e.g., allergies), and accidental injuries (e.g., bone fractures, poisoning) also appear to be higher in children with ADHD than in controls. More accidental injuries may occur in youth with high levels of aggression than in those with hyperactivity alone. Long-term complications associated with ADHD include risk of substance abuse problems; problems in marriage, family cohesiveness, and chronic family conflict; employment difficulties such as frequent job changes, stress on the job, and underemployment; increased health risks such as early cigarette smoking, early sexual activity, increased driving accidents and eating disorders, and sleep disorders in children and adolescents; and risk of comorbid psychiatric disorders.

3. ADHD With Other Disorders

ADHD places individuals at risk for other psychiatric disorders. Oppositional defiant disorder (ODD, 54–67%) and conduct disorders (20–56%) are among the most frequent comorbid disorders in children due to impulsivity and an inability to follow rules. Conduct disorders are also common in teens (44–50%). The presence of ADHD with conduct problems increases the risk of later difficulties, including drug use and abuse, driving accidents, and additional psychiatric problems. Social problems are common in individuals with ADHD, where intrusive, inappropriate, awkward, and/or ineffective behaviors lead to rejection or strained relations with others. Mood disorders are also high (20–36%), with 27 to 30% having anxiety and 15 to 70% having major depression or dysthmia. Stimulant medication might not be as effective in individuals with ADHD plus anxiety, and side effects might be higher than in nonanxious ADHD groups. Learning disabilities are also frequent, with as many as 20 to 50% of children exhibiting significant learning problems due to difficulties with attention, work completion, and disruptive problems in the classroom.

In 1997, Jensen and colleagues cautioned that clinic based longitudinal studies may increase the appearance of comorbidity because persons with more severe and comorbid conditions may be more likely to participate in ongoing studies. Rates of psychiatric comorbidity differ somewhat in community-based studies of children with ADHD. For example, the Multimodal Treatment Assessment (MTA) study of youth with ADHD reported comorbidity rates as follows: In the sample of children, 31.8% had ADHD alone, 33.5% had anxiety, 14.3% had conduct disorders, 39.9% had ODD, 3.8% had an affective disorder, and 10.9% had tic disorders.

Adults with ADHD have comorbidity rates of 16 to 31% for major depression, 24 to 35% for ODD, 17 to 25% for conduct disorders, 4 to 14% for obsessive– compulsive disorders, 35% for alcohol dependence or abuse, 24% for substance abuse (i.e., cannabis or other drugs), 43% for generalized anxiety disorder, and 52% for overanxious disorder. Rates of conduct disorders or antisocial personality disorder are also high in adults with ADHD (22%).

The mechanisms of comorbidity are not well understood, but it appears that ADHD places an individual at risk for other psychiatric disorders and the presence of comorbid disorders interacts with and alters the developmental trajectory and treatment responsivity of ADHD. In 2003, Pliska and colleagues provided an assessment and treatment approach for children with ADHD and comorbid disorders. It is recommended for addressing more complex cases of ADHD.

4. Gender And Cultural Issues

National reports have highlighted the disparity of diagnosis and treatment for mental illness for girls and nonWhite children. Despite similarities in the incidence rates of hyperactivity in Black children, service delivery is lower in Black children than in Whites with similar problems. Referral and treatment rates are lower for girls (three times less likely to receive treatment compared with boys) and for Black children (three times less likely to be referred compared with White children).

There is some evidence that gender differences may be a function of the referral source, that is, clinic referred children versus non-clinic-referred children. In a review of 18 studies on girls with ADHD in 1997, Gaub and Carlson found that nonreferred samples of girls with ADHD, as compared with boys with ADHD, had more intellectual impairments but were less aggressive, were less inattentive, and had lower levels of hyperactivity. However, when compared with clinic referred samples, girls and boys with ADHD had more similarities than differences on core ADHD symptoms.

Other studies of clinic-referred girls indicate that girls with ADD/C are indistinguishable from boys with ADHD on measures of comorbid disorder, behavioral ratings of core symptoms, psychological functioning, and family history of psychopathology. However, when differences did occur, girls had lower reading scores and higher parent-rated measures of inattention. Furthermore, referred girls were a more extreme sample than were boys, with the former having higher rates of familial ADHD. Girls also showed a more positive response to stimulant medication than did boys. In 1999, Biederman and colleagues found similar results in girls referred to pediatricians and psychiatrists. Girls referred for ADHD were more likely to show conduct problems, mood and anxiety disorders, a lower intelligence quotient (IQ), and more impairment on social, family, and school functioning than were nonreferred girls. Conduct problems were lower in girls than in boys with ADHD, and this may account for lower referral rates. However, high rates of mood and anxiety disorders suggest the need for comprehensive treatment. It was of particular note that girls in this study also had high rates of substance abuse disorders, including alcohol, drug, and cigarette use, and were at an increased risk for panic and obsessive– compulsive disorders.

In sum, clinic-referred girls with ADHD present with more symptoms than do girls without ADHD and are indistinguishable from clinic-referred boys with ADHD. It is important to note that girls who are referred for ADHD may represent a more severely impaired group than do community-based samples of girls. Further evidence suggests that girls who are in need of treatment for ADHD may be overlooked because they tend to be less disruptive than boys. Additional longitudinal research investigating gender differences would be helpful to resolve these critical issues.

5. Etiology of ADHD

Research indicates that problems in behavioral inhibition or self-control are a result of dysfunction in frontal– striatal networks, whereas other brain regions (e.g., basal ganglia that includes the caudate nucleus and cerebellum) are also implicated. The evidence of genetic transmission of ADHD, primarily involving the dopamine systems that innervate frontal–striatal regions, is strong. Studies estimate that 70 to 95% of deficits in behavioral inhibition and inattention are transmitted genetically. Research investigating the manner in which the environment interacts with subtle brain anomalies and genetic mutations is ongoing. Traumatic events, the presence of comorbid disorders, and other psychosocial stressors (i.e., poverty, family dysfunction) complicate ADHD but are not considered to be causal.

Although neurological and genetic substrates appear to be compromised, multiple interacting factors are likely involved in the expression of ADHD. It is likely that compromised neural systems influence adaptive functioning and that family, school/work, and community environments affect how ADHD is manifested and may contribute to the development of various coexisting disorders. There may be other factors, including exposure to environmental toxins (e.g., elevated lead exposure), prenatal smoking, and alcohol use, that increase the risk for ADHD. However, these risk factors are not present in all children with ADHD. Some environmental explanations are inaccurate and non-scientifically based, including high sugar ingestion, allergies or sensitivities to foods, family discord, parental alcoholism, poor or ineffective parenting, and poor motivation. Furthermore, inaccurate beliefs about the nature of ADHD often lead to ineffective treatment approaches.

6. Developmental Context For ADHD

Although ADHD has been considered to be a disorder of childhood, there is compelling evidence that a majority of children do not outgrow ADHD. This section highlights the major challenges of ADHD throughout the life span.

6.1. ADHD During Early Childhood

Symptoms of ADHD typically first appear during early childhood. Infants are often described as temperamental, difficult to care for due to excessive crying and irritability, difficultly in calming, overly sensitive to stimulation, and overly active. These complications often interfere with normal parent–child bonding and often lead to negative parental interactions (e.g., fewer interactions, less affection, higher parental stress). These patterns affect child compliance and lead to frustrating and challenging interactions. In preschool, hyperactivity levels are pronounced and lead to difficulty in adjusting to expectations to sit, listen, and get along with other children. Impulsivity interferes with play and often leads to rejection. Referral rates are high during this stage of development as children come into contact with other adults and face greater demands for self-control. Interventions at the stage frequently focus on increasing parenting skills, building positive parent–child relationships, increasing parent support, and implementing other preventive measures (e.g., reinforcing prosocial behaviors, training preschool teachers, using behavioral management principles).

6.2. ADHD During Middle Childhood

Most research on ADHD has been conducted on children between 6 and 12 years of age. Deficits in self-control continue to be problematic and are highlighted by disruptive, noncompliant, and off-task behaviors at home and at school. Poor attention to schoolwork, poor work completion, low motivation, low persistence to challenging tasks, and poor organizational skills negatively affect academic and school adjustment. Difficulties with social situations, negative peer and adult interactions, poor anger control, and low self-esteem create secondary problems that can be chronic. Parent–child relationships are often strained due to noncompliance, failure to complete household chores, and the need for constant monitoring of everyday activities (e.g., bathing, eating, getting dressed, going to bed). These difficulties can increase family stress and interfere with sibling relationships. Other comorbid disorders, including oppositional deviance, conduct problems, depression, and anxiety, may also emerge during this stage. Severe oppositional deviance is problematic and often presages antisocial behavior during later adolescence and adulthood. Treatments during this stage typically are multimodal, including parent training, behavior classroom management, academic interventions, self-management training (e.g., self-instruction, anger control), and medication.

6.3. ADHD During Adolescence

Longitudinal studies reveal significant difficulties for approximately 70 to 80% of teens who had ADHD as young children. Although cognitive deficits and learning disabilities are common in children with ADHD, they are less well documented in adolescents and adults. Longitudinal studies show that youth with ADHD have significant academic difficulties, including high suspension rates (46%), high dropout rates (10%), and placements in special education for learning disabilities (32.5%), emotional disturbance (35.8%), and speech language disorders (16.3%). Negative academic outcomes were present even after intensive treatments, including medication, individual therapy, family therapy, and special education placement. In general, children with hyperactivity are less well educated, have higher rates of grade retention, and have lower grades compared with controls at 5and 10-year follow-ups. Adolescents with ADHD also show higher rates of automobile accidents and speeding tickets than do teens without ADHD. Both cigarette use and marijuana use are higher according to parental reports, whereas teens with ADHD report higher rates of cigarette use but not of alcohol use, or of marijuana, cocaine, heroin, and other illegal substances use, compared with non-ADHD teens. Antisocial behaviors, including theft, breaking and entering, disorderly conduct, carrying a weapon, assault with a weapon, assault with fists, setting fires, and running away from home, were reported in the Milwaukee Longitudinal Study.

In general, treatment options for teens are less well researched than are those for children. Treatment for adolescents with ADHD typically focuses on increasing problem solving and communication between parents and teens, psychopharmacotherapy, and classroom accommodations for academic difficulties. More systematic study is needed to investigate the strength of these various interventions. It has been suggested that children with ADHD might not receive needed treatment.

6.4. ADHD During Adulthood

In 1996, Barkley and colleagues found that adults with ADHD had similar levels of educational achievement and occupational adjustment but differed from controls on symptoms of ADHD and oppositional problems in college and at work. They also had shorter duration of employment, more psychological distress and maladjustment, and more antisocial acts and arrests for disorderly conduct and thefts compared with controls. Even though conduct problems and risk for comorbid antisocial personality disorder appear in approximately 25% of individuals with ADHD, the majority of adults with hyperactivity do not engage in criminal behaviors.

According to driving instructors and self and parent-reports of driving skills, young adults with ADHD were more distractible and impulsive while driving. High rates of driving-related difficulties, including license suspensions or revocations, serious accidents (i.e., involving a wrecked car), and hit-and-run accidents, were also reported. In 1998, Barkley indicated that young adults with ADHD had sexual intercourse at an earlier age, more sexual partners, and higher rates of pregnancy. Contraceptive use was lower, sexually transmitted diseases were higher, and testing for HIV/ AIDS was higher in the ADHD group than in controls. Treatments for adults with ADHD are not well documented but often include multiple approaches, including family and couples therapy, occupational and career counseling, occupational accommodations, medication, and treatment for comorbid disorders (e.g., alcohol or drug treatment, depression, bipolar disorders). Others have emphasized the need for counseling to change the negative mind-set that results from years of failure and coaching for everyday responsibilities. Although empirical studies are needed to determine the efficacy of various treatment options, studies do show the efficacy of stimulant medication in the treatment of ADHD in adults.

7. Evidence-Based Interventions For ADHD

The American Academy of Child and Adolescent Psychiatry (AACAP) has developed practice guidelines for the diagnosis and treatment of ADHD. The American Academy of Pediatrics (AAP) recommends that stimulant medication should not be used as the only treatment for ADHD and should be administered only after a careful evaluation. Practice guidelines recommend a comprehensive multimethod approach for the diagnosis of ADHD in children and youth.

7.1. Multimodal Treatment Regimens

The MTA study, funded by the National Institute for Mental Health, reported that children with ADHD received suboptimal care in the community. Even though two-thirds of the sample received stimulant medication, care in the community was less effective than were carefully managed medication, behavioral treatment, and combined treatments. Only 25% of children receiving care in the community were normalized after a 14-month trial, whereas 68% of the combined group, 56% of the carefully managed medication group, and 34% of the behavioral treatment group showed normalization. When community care is provided, it is not carefully monitored, nor is it as effective as multimodal intensive treatment. The MTA study showed that children with ADHD had the best response to multimodal treatment that included 35 sessions of parent training, a full-time summer treatment program for children to learn social and sports skills and to practice academic skills, weekly teacher consultation, a paraprofessional aide in the classroom, contingency management in the classroom, and medication. This extensive treatment was highly effective in reducing the major symptoms of ADHD and was superior to treatment generally found in the community. It is difficult to discern whether the quality and level of treatment described in the MTA study can be easily implemented in the community.

7.2. Other Evidence-Based Interventions

Other empirically supported treatments for children with ADHD include behavioral therapy and contingency management techniques; a summer treatment program with a systematic reward/response cost program, sports skills training, a 1-hour daily academic special education class, training in effective social skills, daily report cards, and parent training; parent training combined with contingency management and didactic counseling to increase parent knowledge of ADHD; a community-based family therapy program; the good behavior game, response cost, using the ‘‘attention trainer’’; modification of classroom assignments and task demands; and the Irvine Paraprofessional Program. Self-management, direct contingency management, and intensive behavioral and social skills training have also been shown to be effective.

8. Medication Monitoring And Adherence

Research on the short-term efficacy of stimulant medication is well documented for 75 to 80% of children with ADHD; however, medication monitoring and adherence is problematic. For example, in 2001, Vitiello stated, ‘‘For optimal pharmacological treatment of children with ADHD, medication adjustments are needed for long-term treatment even when the initial dose is chosen in a careful, comprehensive, and unbiased manner.’’ In the MTA study, more than 70% of children assigned to the medical management group were on different doses after a 13-month trial. Although the majority of children receiving community care in the MTA study were treated with stimulant medication, as a whole, children in the medical management group received more careful medication monitoring from physicians and showed greater improvement of symptoms than did children in the care in the community group.

In 2001, Thiruchelvam and colleagues investigated medication adherence in children 6 to 12 years of age. The most salient factors affecting compliance were the absence of ODD, the severity of ADHD symptoms, and the age of the children. Children with ODD were 11 times more likely to refuse medication. Youth with more symptoms were more responsive to the medication and were more compliant when taking medication as well. Positive stimulant response may encourage parents and children to stick to the medication regimen at higher rates than in cases where medication is not very helpful. Older children were also more likely to refuse medication. Because there is a decrease in hyperactivity symptoms with age, older children may perceive less benefit from medication and choose not to adhere. Social stigma may also play a role in adherence at this stage. Physicians are advised to develop adherence plans for youth on medication.

In sum, research indicates that multiple therapies are needed to adequately address the problems associated with ADHD. Stimulant medication with behavioral and psychosocial interventions, including classroom behavior management and parent management training, improve ADHD symptoms and associated problems in children with ADHD. Initial research indicates that stimulant medication is effective for adults and that other cognitive–behavioral interventions (e.g., self-management) show promise. Currently, treatment within a single modality (medication vs behavioral) appears to have very little long-term impact. Effective treatments are less well documented for adolescents and adults with ADHD. Although studies have shown that stimulant medication is effective, less is known about the effects of multimodal treatment in older groups.

9. Risk And Resiliency Factors That Affect ADHD

Although ADHD presents challenges throughout the life span, some factors complicate the disorder, whereas others appear to be protective. Risk factors that alter the course of ADHD include child characteristics (e.g., severity of ADHD symptoms, intelligence levels, comorbidity), family discord or environmental distress, and early treatment for ADHD and the presence of coexisting disorders. In an effort to optimize outcome, comorbid disorders should be targeted for treatment along with the ADHD symptoms. Oppositional defiant behavior problems are among the most debilitating difficulties over time because they often lead to conduct disorders and antisocial personality disorders during adolescence and adulthood. There is evidence that effective parenting skills can interrupt this progression in many children. Other family factors that increase the complexity of ADHD include parental psychopathology such as maternal depression and paternal antisocial personality disorder. These parental difficulties often interfere with effective parenting and produce added stress to vulnerable families whose members are already challenged by disruptive noncompliant child behaviors. There is strong evidence that raising a child with ADHD is stressful, so additional parental problems make this challenge even more overwhelming. Furthermore, as noted by Goldstein in 2002, ‘‘Living in a household, above the poverty level, with parents who are free of serious psychiatric problems, consistent in their parenting style, and available to their children appear to be among the most powerful variables at predicting good outcome.’’ Parents are also advised to seek individual and family therapy for their own problems in an effort to strengthen interpersonal effectiveness and family cohesiveness.

The extent to which treatment alters the developmental course of ADHD is not well understood. Some studies of children who received extensive treatment showed that these youth still had poor outcomes during adolescence. However, the MTA study showed short-term improvement (over a 14-month period) in children receiving comprehensive multimodal treatment in highly controlled and monitored programs. Furthermore, growing evidence suggests that medication may buffer some of the negative effects of ADHD. Although there are reasons to be cautious about the use of stimulant medication in young children, recent studies suggest that early treatment may alter the neurodevelopmental pathways of ADHD in positive ways. Stimulant treatment also appears to improve outcomes for adults. In 1999, Wilens and colleagues also found that 70% of adults receiving a year of cognitive therapy and stimulant medication showed a reduction of ADHD symptoms and were less anxious and depressed.

Current studies of ADHD are focusing on the long-term effects of multimodal treatment for children and are investigating what works best for adolescents and adults with ADHD. Current research is promising, but researchers are still exploring how the outcome and course of ADHD can be altered with effective treatments. The impact of environmental events on the development of attention and self-regulation is of particular interest.

References:

Barkley, R. A. (1997). ADHD and the nature of self-control. New York: Guilford.
Barkley, R. A. (1998). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment New York: Guilford. Barkley, R. A., & Gordon, M. (2002). Research on comorbidity, adaptive functioning, and cognitive impairments in adults with ADHD: Implications for a clinical practice. In S. Goldstein, & A. Teeter Ellison (Eds.), A clinician’s guide to adult ADHD: From evaluation to treatment (pp. 43–69). San Diego: Academic Press.
Barkley, R. A., Murphy, K., DuPaul, G., & Bush, T. (2002). Driving in young adults with attention deficit
hyperactivity disorder: Knowledge, performance, adverse outcomes, and the role of executive functioning. Journal of the International Neuropsychological Society, 8, 655–672.
Castellanos, F. X., Lee, P., Sharp, W., Jeffries, N., Greenstein, D., Clasen, L., Bluementhal, J., James, R., Ebens, C., Walter, J., Zijdenbos, A., Evans, A., Giedd, J. N.,
& Rapoport, J. L. (2002). Developmental trajectories of brain volume abnormalities in children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Medical Association, 288, 1740–1748.
DuPaul, G., & Stoner, G. (2003). ADHD in the schools: Assessment and intervention strategies (2nd ed.). New York: Guilford.
Gaub, M., & Carlson, C. L. (1997). Gender differences in ADHD: A meta-analysis and critical review. Journal of the Academy of Child and Adolescent Psychiatry, 36, 1036–1045.
Goldstein, S. (2002). Continuity of ADHD in adulthood: Hypothesis and theory meet reality. In S. Goldstein, & A. Teeter Ellison (Eds.), Clinician’s guide to adult ADHD: Assessment and intervention (pp. 25–45). London: Academic Press.
Leibson, C. L., Katusic, S. K., Barbaresi, W. J., Ransom, J., & O’Brien, P. C. (2001). Use and cost of medical care for children and adolescents with and without attention deficit/hyperactivity disorder. Journal of the American Medical Association, 285, 60–66.
MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/ hyperactivity disorder. Archives of General Psychiatry, 56, 1073–1086.
Pliszka, S. R., Carlson, C. L., & Swanson, J. (2003). ADHD with comorbid disorders: Clinical assessment and management. New York: Guilford.
Tannock, R. (1998). Attention deficit hyperactivity disorder: Advances in cognitive, neurobiological, and genetic studies. Journal of Child Psychology and Psychiatry, 39, 65–100.
Teeter, P. A. (1998). Interventions for ADHD: Treatment in developmental context. New York: Guilford.
Teeter Ellison, P. A. (2002). An overview of childhood and adolescent ADHD: Understanding the complexities of development into the adult years. In S. Goldstein, & A. Teeter Ellison (Eds.), Clinician’s guide to adult ADHD: Assessment and intervention (pp. 2–19). London: Academic Press.
Thiruchelvam, D., Charach, A., & Schachar, R. J. (2001). Moderators and mediators of long-term adherence to stimulant treatment in children with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 922–928.
Vitiello, B. (2001). Psychopharmacology for young children: Clinical needs and research opportunities. Pediatrics, 108, 983–989.
Wilens, T. E., McDermott, S. P., Biederman, J., & Abrantes, A. (1999). Cognitive therapy in the treatment of adults with ADHD. Journal of Cognitive Psychotherapy, 13, 215–226.