During the 2-day meeting, delegates had the opportunity to attend a variety of interesting clinical seminars across a range of topics, such as: behavioural interventions for childhood ADHD; utilisation of pharmacological treatment across a lifespan; comorbid anxiety disorders; trauma and emotional dysregulation in children with ADHD; ADHD neurobiology; and presentation of a Canadian model for primary care of ADHD across the lifespan.
Behavioural interventions for ADHD in childhood: why do we need them?
Professor David Daley (University of Nottingham, UK) first presented results from a meta-analysis that aimed to assess the broader impact of behavioural interventions for children with ADHD.1 The results demonstrated that for assessments made by individuals closest to the treatment setting (usually unblinded), there were significant improvements in parenting quality (standardised mean difference [SMD] for positive parenting = 0.68; negative parenting [SMD = 0.57]; and parenting self-concept [SMD = 0.37]) and child ADHD (SMD = 0.35), conduct problems (SMD = 0.26), social skills (SMD = 0.47) and academic performance (SMD = 0.28).1 For probably blinded assessment, significant effects persisted for parenting (positive parenting [SMD = 0.63] and negative parenting [SMD = 0.43]) and conduct problems (SMD = 0.31).1 Professor Daley highlighted that this suggests that behavioural interventions have a positive effect on a range of outcomes in children with ADHD.1 Moreover, there is blinded evidence that behavioural interventions improve parenting and reduce childhood conduct problems, which may lead to more positive parental self-concept but not necessarily improved parental well-being.1
Are tailored interventions better than more generic interventions?
Professor Daley informed delegates that there is at least one behavioural programme, the New Forest Parenting Programme, which has been designed to target the underlying features of ADHD (e.g. self-regulation and cognitive problems) on the basis that this will lead to better effects on core symptoms.2,3 Professor Daley highlighted one randomised controlled trial which showed that the ADHD-specific New Forest Parenting Programme did not demonstrate greater efficacy on child behaviour (ADHD and conduct problems), parental stress and parenting practices compared with a generic parent approach (Helping the Noncompliant Child).4
Who should deliver the behavioural interventions?
There is no meta-analytical evidence or studies that have systematically varied the amount of training or supervision to address this question. Professor Daley did point out that one randomised controlled trial found that the effects of behavioural interventions were reduced to non-significance when interventions were implemented by randomly selected therapists delivering treatment as part of their everyday caseload compared with specialist therapists working as part of a clinical trial.5
Should we focus on parents who have clear parenting difficulties?
Professor Daley stated that inclusion into previous studies has been based on children having ADHD rather than on parents having a lack of parenting abilities. He did highlight that improvements in parenting do mediate the link between behavioural interventions and change in behaviour problems for children who are at risk of conduct problems.6 Professor Daley noted that there is no evidence to suggest that improvements in parenting as result of behavioural interventions occur only in families with low pre-existing parenting skills or deficits.
Are parent preferences important?
Professor Daley opined that parent preferences are important. A large study (n = 445 parents) showed that 58.7% of parents of children with ADHD had a preference for individual parent training and wanted to feel more informed about their child’s problems and to understand as opposed to solve their child’s difficulties.7 In the same study, 19.4% of parents preferred group-based therapy and 21.9% preferred a minimal information alternative (i.e. receiving neither individual or group parent training).7 However, these parents reported the highest levels of depression and the most severe mental health problems in their child.7 Professor Daley said that this may indicate that not all help-seeking parents are looking or willing to engage in behavioural interventions.
Is early intervention more effective?
Professor Daley thought that many randomised controlled trials have mainly focussed on pre-school and primary school-aged children with ADHD and most meta-analyses do not report a significant impact of age on the outcomes of behavioural interventions. He did point out one meta-analysis study which found larger effects of behavioural interventions in younger children on unblinded ADHD measures (t = –2.09, p = 0.05), conduct problems (t= –2.46, p = 0.03) and positive parenting (t= –2.63, p = 0.03).1
Clinical discussion with delegates
Professor Daley then posed the following question to delegates: “Do you use behavioural interventions? If so, how, why and how do you decide who uses them? And are they sufficient?” This generated considerable discussion surrounding clinical practice across various countries including France, Mexico, Portugal and Germany. Many clinicians were using some form of behavioural intervention (e.g. parent training for managing conduct problems or The Incredible Years® Programme). The discussions highlighted that group-based parenting training may not be sufficient due to the heterogeneity of the group (e.g. parents of children with ADHD, conduct problems or autism spectrum disorder) and that it may be more difficult to know which core symptoms to target as each strategy does not work for each disorder. In Professor Daley’s view, shorter behavioural interventions might be better as they allow clinicians to see more parents. Additionally, he pointed out that not all behavioural interventions teach parents how to modify their training as their child grows.
|Professor Daley concluded his presentation with the following take-home messages:
Professor Daley: “Behavioural interventions should be modified over time as the child develops and child self-regulation should be promoted”
Utilising pharmacological treatment choice in clinical practice (lifespan)
Professor David Coghill (University of Melbourne, Australia) opened this presentation by noting that countries have different access to treatment. He explained that the objective of this clinical seminar was to not talk about treatments per se, but treatment order to ensure optimisation of treatment. The seminar covered the following three topics:
- What the evidence says about which treatments work, and if one treatment is better than the other
- In newly diagnosed individuals which medication should be used first, and how to monitor treatment
- Treatment decisions when subsequent treatments are not working optimally
Professor Coghill began by reviewing a 2018 article by Cortese and colleagues published in The Lancet Psychiatry which was a network meta-analysis on the comparative efficacy and tolerability of medications for ADHD across the lifespan.8 He first explained, in his own words, the differences between a meta-analysis and a network meta-analysis:
- Meta-analysis: a statistical way to compare a group of studies to show how treatments are effective versus placebo, where the SMD is the effect size – an effect size of 0.8 is considered large, 0.5 medium and 0.3 small – and you can see if one treatment is better than another. Confidence intervals show the statistical differences and if the confidence interval does not cross zero, a treatment is statistically improved compared with placebo.
- Network meta-analysis: allows you to compare a range of treatments with each other. Each of the nodes (bubbles) is a different treatment, and the size of the bubble is dependent on the number of studies included in the analysis (the bigger the bubble, the more studies there are). The lines show there is a direct comparison between one drug and another, or placebo (the thicker the line the greater number of individuals). He explained that a network meta-analysis allows not only direct comparisons of studies that are linked but also indirect comparisons.
The network meta-analysis by Cortese et al included 133 double-blind randomised controlled trials (81 in children and adolescents, 51 in adults, and one in both).8 The analysis of efficacy closest to 12 weeks was based on 10,068 children/adolescents and 8,131 adults; and the tolerability analysis was based on 11,018 children/adolescents and 5,362 adults.8
Professor Coghill noted that the key difference between the network meta-analysis of the adult studies compared with the child/adolescent studies was that there were fewer studies, fewer pharmacological treatment options, fewer head-to-head studies, fewer participants and fewer clinical studies.8
Professor Coghill went on to highlight key results from the study which showed that at 12 weeks, all treatments (amfetamine, atomoxetine, bupropion, clonidine, guanfacine, methylphenidate and modafinil) were more effective than placebo in children and adolescents – with amfetamine being the most effective.8 He also noted that there were only a small number of bupropion studies in children and adolescents, hence the confidence intervals had a wide variance. In the adult studies, amfetamine, atomoxetine, bupropion and methylphenidate were more effective than placebo; however, modafinil was not more effective than placebo.8
Regarding tolerability, all pharmacological treatments were numerically worse than placebo in children and adolescents, and amfetamine and guanfacine were statistically worse than placebo.8 In adults, all treatments were statically worse than placebo, except bupropion which was worse – but not statistically so – than placebo, which again could possibly be due to the small number of studies included.8
Professor Coghill went on to explain that the network meta-analysis results showed that when the pharmacological treatments were directly compared with each other and placebo, results showed that all treatments were superior to placebo in children/adolescents and adults.8 He concluded that when taking into account both efficacy and safety, the evidence supports the use of methylphenidate in children and adolescents, and amfetamines in adults, as the first-choice treatment option at the group level in the short term, and that there was a paucity of long-term randomised controlled trials.
Dr Jakob Ørnberg (Aarhus University Hospital, Denmark) pointed out that even with this article and its recommendations, treatment should be tailored to specific individuals as it cannot be predicted which individual will respond best to which treatment. The audience agreed that when consulting with someone newly diagnosed with ADHD it was better to say that there are many different treatments to try and the one that you are giving them is the first, as you do not know if it will be the best option for them. As a clinician you then see how the individual responds and tailor the treatment accordingly.
Professor Coghill opened the second half of the clinical seminar by noting that the guidelines state that treatment should be titrated but do not describe how to do so. He then presented the Dundee ADHD Clinical Care Pathway,9 beginning by describing the titration protocol which starts with a 4-week protocoled titration focusing on symptom reduction and optimising treatment in order to provide maximum benefit at a minimum dose. He noted that the protocol should almost always be started with a stimulant.9
He went on to explain that the Dundee ADHD Clinical Care Pathway is delivered by nurses, with support from a senior clinician if required, with a fixed protocol with validated outcome measurements for continuing care. In addition to feedback from the individual with ADHD and parent/carer, the following information is gathered at baseline and each subsequent titration appointment:9
- ADHD Rating Scale-IV (ADHD-RS-IV) or Swanson, Nolan and Pelham Teacher and Parent Rating Scale-IV (SNAP-IV) (clinician-delivered)
- Swanson, Kotkin, Agler, M-Flynn, and Pelham Scale (SKAMP) (teacher)
- Height, weight, pulse and blood pressure
- Adverse events (framed as ‘other symptoms’)
- Screen for ‘other problems’ and arrange treatment as required
With regards to treatment, if the first-choice stimulant does not work at all, it is important to consider switching to another stimulant, and if the first-choice stimulant is not tolerated, depending on the situation, the clinician should consider the other stimulant class or switch to a non-stimulant.9
|Professor Coghill concluded this clinical seminar by listing a series of questions that he believes clinicians should ask themselves before switching to a different pharmacological treatment:
Professor Coghill: “My one principle in pharmacology is to change only one thing at a time and to change them sequentially… In the end you are more likely to get it right”
Disentangling inattention from ADHD or anxiety disorder (lifespan)
Professor Luis Rohde (Federal University of Rio Grande do Sul, Porto Alegre, Brazil) began his clinical seminar by stating that ADHD is associated with psychiatric comorbidity, and it has been reported that up to 50% of children and adolescents with ADHD meet the criteria for a comorbid anxiety disorder.10 The presence of ≥2 anxiety comorbidities in children with ADHD is associated with poorer quality of life, daily functioning and behaviour compared with children with ADHD but without anxiety.10 Professor Rohde stated that in his view, it is important that clinicians pay attention to comorbidities as this can lead to a higher level of impairment.
|Professor Rohde presented the following hypothetical clinical vignette and asked delegates for their clinical opinion:
In response to this hypothetical clinical vignette, delegates then queried the following:
Professor Rohde stated that this hypothetical clinical vignette was constructed to show that individuals may develop compensatory strategies to manage their impairment; however, when the environment changes (i.e. transition from school to college) this can lead to a breakdown in coping strategies. Professor Rohde indicated that this hypothetical individual would be diagnosed with anxiety due to not being able to compensate for ADHD. In his opinion, Professor Rohde stated that individuals with generalised anxiety disorder (GAD) might present clear symptoms of inattention that are related to rumination of worries but may mimic ADHD-related inattention. He noted that hyperactivity/restlessness could also be a symptom of both GAD and ADHD. Professor Rohde highlighted that it may be clinically relevant to characterise the worries/dysfunctional thoughts if it is unclear whether an individual is presenting with symptoms of GAD or ADHD. For example, in his view, Professor Rohde stated that moments of enjoyable ‘mind wandering’ without signs of tension/anxiety associated with ADHD is very different to worries or dysfunctional thoughts associated with anxiety.
Professor Rohde pointed out that there were few markers that could help disentangle ADHD from anxiety disorders and diagnosis was still reliant on clinical wisdom. However, he did mention that there is evidence to suggest that:
- Children with distress-related disorder are more vigilant towards threat-bias than those with a behavioural disorder11
- Poorer information processing is specific to children with ADHD compared with those without ADHD12
- Motor activity, in the context of working memory demands, might be more specific for adults with ADHD compared with those with GAD or healthy adults13
- For children and adolescents with ADHD, the acute effects of methylphenidate on core ADHD symptoms are unaffected by a comorbid anxiety disorder14
Professor Rohde: “Taking a family history of anxiety and/or ADHD is very important”
ADHD, trauma and emotional dysregulation in children
Professor Jeffrey Newcorn (Mount Sinai Medical Center, USA) opened this interactive clinical seminar by discussing the topic of ADHD and abuse. He presented results from a large population study (n = 2,480) of youths in Boricua15 which found a direct relationship between trauma and ADHD, and that in girls, physical abuse had a 3-fold increase in the odds of having an ADHD diagnosis; and in boys, associations were observed only for emotional abuse. It was also noted that sexual abuse was not related to ADHD. Persistence and severity of ADHD were also related to trauma and the study found that multi-abuse and comorbidity increased the link to ADHD.
This study was supported by results from a community-based study of children aged 6‒8 years from Australia which showed that children with ADHD were more likely to have experienced a traumatic event compared with controls. The study also found that there were no significant differences observed in the functioning of children with ADHD with or without trauma exposure;16 however, Professor Newcorn noted that findings do differ between studies. He went on to show results from a systematic review and meta-analysis which demonstrated that individuals with post-traumatic stress disorder were at risk of ADHD and that individuals with a diagnosis of ADHD were at risk of post-traumatic stress disorder.17
Professor Newcorn then discussed his own experience surrounding ADHD and emotional dysregulation which he described in three categories:
- Clinical: Many individuals with ADHD report difficulties with handling emotions/affect, which adversely impact development and functioning, and that this is often a focus of clinical intervention; however, there are few data investigating this topic
- Nosologic: There is considerable confusion regarding the role of emotional dysregulation in ADHD; for example, is it associated with or constitutive of ADHD? Furthermore the boundaries between emotional dysregulation and mood disorders are poorly defined and may appear to overlap
- Scientific: There is interest in elucidating brain mechanisms subserving self-regulation, and ADHD offers a model for understanding the inter-relationships among cognitive, behavioural and affective regulatory circuits, and that the expanded conceptualisation of ADHD provides a basis for understanding high comorbidity with aggression and disruptive behaviour disorders
Professor Newcorn described the functional consequences of emotional dysregulation in ADHD, whereby emotional dysregulation in children contributes independently from ADHD symptoms to functional impairment in several areas such as: prediction of suspensions and expulsions from school; impairments in social, daily living and adaptive skills; and higher treatment service utilisation.18 The presence of emotional dysregulation in youths with ADHD was also found to predict lower likelihood of remission. Emotional dysregulation in adults was found by Faraone and colleagues to be associated with a lower likelihood of graduating high school or college; poorer peer relations; lower employment rate, greater number of jobs held, poorer work performance, greater likelihood of being fired or quitting from boredom, and greater financial difficulties; and higher rates of driver license suspensions and traffic tickets.
Professor Newcorn then went on to discuss the two dimensions of emotional dysregulation in ADHD:18
1. Dysregulation of emotion generation
- Low capacity for enjoyment (anhedonia, low hedonic tone)
- Excessive alarm to stimuli (anxiety)
- Excessive sadness/euphoria (depression/mania)
- Excessive frustration to mildly noxious stimuli (irritability)
2. Impaired emotion regulation
- Difficulty exerting purposeful control over emotions
- Emotional responses can be exaggerated in intensity, duration or form of expression
- Autonomic, behavioural and cognitive sequelae of emotion expression exceeds developmental level
The pathways of emotional reactivity in individuals with ADHD and emotional lability were then described and compared in three phases as follows:18
|Individuals with ADHD
High Emotional Impulsivity and Deficient Self-Modulation
|Individuals with emotional lability
High Emotional Impulsivity and Effective Self-Modulation
|Phase 1||High emotional impulsivity causes emotion generation at lower thresholds, shorter rise times and intense emotional responses||High emotional impulsivity causes emotion generation at lower thresholds, shorter rise times and intense emotional responses|
|Phase 2||Due to poor self-modulation skills the intensity of behavioural expression is excessive for the level of emotional response||There is a closer relationship between subjective emotional intensity and behavioural expression. Effective self-modulation of emotions shortens the peak|
|Phase 3||Poor self-modulation skills and high levels of emotion generation lead to slower recovery times and prolonged episodes of behavioural disturbance||Emotional self-modulation skills return subjective emotionality and expressive behaviours to baseline, but high emotional impulsivity carries risk for another episode of extreme emotion|
A group discussion followed, facilitated by Dr Declan Quinn (University of Saskatchewan, Canada), where the audience agreed that as trauma and emotional dysregulation has such a big impact on the future of individuals with ADHD it should always be considered as part of patient-centred management.
Professor Newcorn: “Emotional dysregulation is highly prevalent in ADHD and cannot be accounted for by the presence of other comorbid conditions”
Neurobiology of ADHD across the life course: attention, affect and impulsivity
This seminar was led by Dr Joseph Sergeant (Free University, Amsterdam, The Netherlands) and Professor Tobias Banaschewski (Central Institute of Mental Health, Mannheim, Germany). A series of images and videos was shown to explain some of the neurobiology of ADHD.
A simulating discussion with the delegates followed this presentation, where Dr Sergeant and Professor Banaschewski were questioned about the effects of substance use disorder on the neurobiology of ADHD, whether the activation/deactivation of genes across a lifespan can play a role in ADHD neurobiology and whether pharmacological treatment can also have an impact.
Dr Sergeant: “MRI scans look wonderful… you see what you get”
A focus on ADHD, across the lifespan, in primary care – learnings from a Canadian model (CanREACH)
Dr Sam Chang (University of Calgary, Canada) and Dr Rick Ward (Crowfoot Village Family Practice, Canada) opened this interactive session by posing the following question to the audience: “What do you think are the biggest gaps in the treatment of ADHD in your country?” Examples of their responses included:
- Misdiagnosis of ADHD
- Lack of confidence, knowledge and awareness of primary care physicians in diagnosing ADHD
- Lack of services
- Limited accessibility and number of specialist psychiatrists
Dr Chang noted that ~3.4‒7% of children and adolescents19-21 and ~2.8% of adults22 have ADHD and the audience agreed that too few children, adolescents and adults with ADHD were actually being treated for ADHD, thus giving weight to the importance of delivering an integrated approach between experts and primary care physicians to deliver services across the lifespan.
Dr Ward then explained the “Patient’s Medical Home” (PMH) which is a vision developed by the College of Family Physicians of Canada to support family physicians and their teams in providing coordinated, comprehensive, accessible care to their patients.23 He stressed the importance of the patient-centred management approach starting with the individuals’ own personal family physician at the centre to provide continuity of care, with support from psychologists and nurses. He also noted that the PMH also provides education to medical students and other health services. The impact of PMHs in Alberta, Canada, has been individuals with ADHD being healthier, hospitalised less, improved quality of life, improved access to appointments, higher patient satisfaction, higher provider satisfaction, and cost savings for the health system.23
Dr Chang explained that the CanREACH programme models how people effectively learn using practical and interactive tools, modelling through role play and repeated interventions over time. The aims of the CanREACH programme are to:
- Increase knowledge in a sustainable manner
- Improve ability to identify mental health concerns and refer when needed
- Offer practical tools for management and reliable and easy to use information
The CanREACH programme consists of a 3-day, face-to-face workshop followed by 6 months of bi-weekly, hour-long, small-group consultation calls, where participants take turns in presenting challenging cases from their own practice and are assisted by the other participants (10‒15 in a group) and two trained faculty to address the assessment and management challenges.24
Dr Chang presented the results from the within- and between-group comparisons which showed that CanREACH-trained physicians were better able to identify and manage child and adolescent mental health issues within their primary care practices which led to fewer referrals to specialised services and the emergency services, suggesting improvements in their practice.24
It was noted that the CanREACH programme is now being rolled out in other states across Canada and it was agreed that CanREACH could fill many of the health service gaps in various countries internationally.
Dr Chang: “It isn’t about what you are taught, it is about how you are taught… It’s about teaching people about assessment, diagnosis, risk, next steps (e.g. rating scales), other symptoms (e.g. comorbidities such as depression) and then what the data shows… Once you have got the concept you can treat ADHD across the lifespan”
Dr Ward: “The CanREACH programme aims to empower family practice to manage the promotion of self-efficacy and knowledge”
- Daley D, van der Oord S, Ferrin M, et al. Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains. J Am Acad Child Adolesc Psychiatry 2014; 53: 835-847.
- Early Intervention Foundation. The New Forest Parenting Programme. Available at: https://guidebook.eif.org.uk/programmes/the-new-forest-parenting-programme. Accessed November 2019.
- Sonuga-Barke E, Thompson M, Abikoff H, et al. Nonpharmacological interventions for preschoolers with ADHD. Infants Young Children 2006; 19: 142-153.
- Abikoff HB, Thompson M, Laver-Bradbury C, et al. Parent training for preschool ADHD: a randomized controlled trial of specialized and generic programs. J Child Psychol Psychiatry 2015; 56: 618-631.
- Sonuga-Barke EJ, Thompson M, Daley D, et al. Parent training for attention deficit/hyperactivity disorder: is it as effective when delivered as routine rather than as specialist care? Br J Clin Psychol 2004; 43: 449-457.
- Gardner F, Hutchings J, Bywater T, et al. Who benefits and how does it work? Moderators and mediators of outcome in an effectiveness trial of a parenting intervention. J Clin Child Adolesc Psychol 2010; 39: 568-580.
- Wymbs FA, Cunningham CE, Chen Y, et al. Examining parents’ preferences for group and individual parent training for children with ADHD symptoms. J Clin Child Adolesc Psychol 2016; 45: 614-631.
- Cortese S, Adamo N, Del Giovane C, et al. Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. Lancet Psychiatry 2018; 5: 727-738.
- Coghill D, Seth S. Effective management of attention-deficit/hyperactivity disorder (ADHD) through structured re-assessment: the Dundee ADHD Clinical Care Pathway. Child Adolesc Psychiatry Ment Health 2015; 9: 52.
- Sciberras E, Lycett K, Efron D, et al. Anxiety in children with attention-deficit/hyperactivity disorder. Pediatrics 2014; 133: 801-808.
- Salum GA, Mogg K, Bradley BP, et al. Threat bias in attention orienting: evidence of specificity in a large community-based study. Psychol Med 2013; 43: 733-745.
- Salum GA, Sergeant J, Sonuga-Barke E, et al. Specificity of basic information processing and inhibitory control in attention deficit hyperactivity disorder. Psychol Med 2014; 44: 617-631.
- Lea SE, Matt Alderson R, Patros CHG, et al. Working memory and motor activity: a comparison across attention-deficit/hyperactivity disorder, generalized anxiety disorder, and healthy control groups. Behav Ther 2018; 49: 419-434.
- Garcia SP, Guimaraes J, Zampieri JF, et al. Response to methylphenidate in children and adolescents with ADHD: does comorbid anxiety disorders matters? J Neural Transm (Vienna) 2009; 116: 631-636.
- Gonzalez RA, Velez-Pastrana MC, McCrory E, et al. Evidence of concurrent and prospective associations between early maltreatment and ADHD through childhood and adolescence. Soc Psychiatry Psychiatr Epidemiol 2019; 54: 671-682.
- Schilpzand EJ, Sciberras E, Alisic E, et al. Trauma exposure in children with and without ADHD: prevalence and functional impairment in a community-based study of 6-8-year-old Australian children. Eur Child Adolesc Psychiatry 2018; 27: 811-819.
- Spencer AE, Faraone SV, Bogucki OE, et al. Examining the association between posttraumatic stress disorder and attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. J Clin Psychiatry 2016; 77: 72-83.
- Faraone SV, Rostain AL, Blader J, et al. Practitioner Review: Emotional dysregulation in attention-deficit/hyperactivity disorder – implications for clinical recognition and intervention. J Child Psychol Psychiatry 2019; 60: 133-150.
- Polanczyk GV, Salum GA, Sugaya LS, et al. Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry 2015; 56: 345-365.
- Polanczyk G, de Lima MS, Horta BL, et al. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry 2007; 164: 942-948.
- Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics 2012; 9: 490-499.
- Fayyad J, Sampson NA, Hwang I, et al. The descriptive epidemiology of DSM-IV Adult ADHD in the World Health Organization World Mental Health Surveys. Atten Defic Hyperact Disord 2017; 9: 47-65.
- Patient’s Medical Home. Implementation Kit. Available at: https://patientsmedicalhome.ca/files/uploads/PMH2019_ImplementKit_AB.pdf Accessed November 2019.
- McCaffrey ESN, Chang S, Farrelly G, et al. Mental health literacy in primary care: Canadian Research and Education for the Advancement of Child Health (CanREACH). Evid Based Med 2017; 22: 123-131.