Symptom and Demographic Predictors of Psychotropic Medication use in ADHD and Autism
DOI:
https://doi.org/10.12970/2310-8231.2019.07.03Keywords:
Psychotropic medication, symptoms, demographics, ADHD-Combined, ADHD-Inattentive, autism.Abstract
ADHD symptoms, oppositional behavior, aggression, and irritability are common in children with ADHD-Combined and autism and are often targeted for treatment with medication. The goal of our study was to determine symptom, diagnostic, and demographic variables that influence the classes of psychotropic medications used to treat children with ADHD-Combined, ADHD-Inattentive, and autism. The sample comprised 1,407 children with autism and 1,036 children with ADHD (without autism) 2-17 years of age. Medications most often prescribed were ADHD medications (22% stimulant, 2% atomoxetine), 8% antipsychotic, 6% SSRI, and 5% alpha agonist. Children with ADHD-Combined and children with autism did not differ in the proportion prescribed a psychotropic and were more likely to be treated with medication than children with ADHD-Inattentive. ADHD severity ratings, oppositional defiant disorder, conduct disorder, anxiety, depression, irritability, and low IQ increased the likelihood of medication use and predicted medication classes. Older age was the most significant predictor of medication treatment. Race, sex, and parent occupation were not predictors. The findings were positive in that symptoms and not demographics determined medication treatment. Interestingly, the presence of learning problems was not a predictor of medication use, despite studies showing that ADHD medication can improve academic performance.
References
Mayes SD, Sanderson DL, Bixler EO, Humphrey FJ, Mattison RE. Methylphenidate and ADHD: Influence of age, IQ, and neurodevelopmental status. Dev Med Child Neurol 1994; 36: 1099-1107. https://doi.org/10.1111/j.1469-8749.1994.tb11811.x
MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999; 56: 1073-86. https://doi.org/10.1001/archpsyc.56.12.1073
Waxmonsky J, Pelham WE, Gnagy E, Cummings MR, O’Connor B, Majumdar A, et al. The efficacy and tolerability of methylphenidate and behavior modification in children with attention-deficit/hyperactivity disorder and severe mood dysregulation. J Child Adolesc Psychopharmacol 2008; 18: 573-88. https://doi.org/10.1089/cap.2008.065
Arnold LE, Aman MG, Cook AM, Witwer AN, Hall KL, Thompson S, et al. Atomoxetine for hyperactivity in autism spectrum disorders: Placebo-controlled crossover pilot trials. J Am Acad Child Adolesc Psychiatry 2006; 45: 1196-1205. https://doi.org/10.1097/01.chi.0000231976.28719.2a
Handen BL, Johnson CR, Lubetsky M. Efficacy of methylphenidate among children with autism and symptoms of attention-deficit hyperactivity disorder. J Autism Dev Disord 2000; 30: 245-55. https://doi.org/10.1023/A:1005548619694
Harfterkamp M, Buitelaar JK, Minderaa RB, van de Loo-Neus G, van der Gaag RJ, Hoekstra PJ. Atomoxetine in autism spectrum disorder: No effects on social functioning; some beneficial effects on stereotyped behaviors, inappropriate speech, and fear of change. J Child Adolesc Psychopharmacol 2014; 24: 481-5. https://doi.org/10.1089/cap.2014.0026
Harfterkamp M, van de Loo-Neus G, Minderaa RB, van der Gaag RJ, Escobar R, Schacht A, et al. A randomized doubleblind study of atomoxetine versus placebo for attentiondeficit/hyperactivity disorder symptoms in children with autism spectrum disorder. J Am Acad Child Aolesc Psychiatry 2012; 51: 733-41. https://doi.org/10.1016/j.jaac.2012.04.011
RUPP. Randomized, controlled, crossover trial of methylphenidate in pervasive developmental disorders with hyperactivity. Arch Gen Psychiatry 2005; 62: 1266-74. https://doi.org/10.1001/archpsyc.62.11.1266
Aman MG, Binder C, Turgay A. Risperidone effects in the presence/absence of psychostimulant medicine in children with ADHD, other disruptive behavior disorders, and subaverage IQ. J Child Adolesc Psychopharmacol 2004; 14: 243-54. https://doi.org/10.1089/1044546041649020
Gadow KD, Arnold LE, Molina BSG, Findling RL, Bukstein OG, Brown NV. Risperidone added to parent training and stimulant medication: Effects on attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, and peer aggression. J Am Acad Child Adolesc Psychiatry 2014; 53: 948-59. https://doi.org/10.1016/j.jaac.2014.05.008
Snyder R, Turgay A, Aman M, Binder C, Fisman S, Carroll A. Effects of risperidone on conduct and disruptive behavior disorders in children with subaverage IQs. J Am Acad Child Adolesc Psychiatry 2002; 41: 1026-36. https://doi.org/10.1097/00004583-200209000-00002
Nagaraj R, Singhi P, Malhi P. Risperidone in children with autism: Randomized, placebo- controlled, double-blind study. J Child Neurol 2006; 21: 450-5. https://doi.org/10.1177/08830738060210060801
Kollins S, Lopez FL. Psychomotor functioning and alertness with guanfacine extended release in subjects with attentiondeficit/hyperactivity disorder. J Child Adolesc Psychopharmacol 2011; 21: 111-20. https://doi.org/10.1089/cap.2010.0064
Newcorn JH, Stein MA, Childress AC, Youcha S, White C, Enright G, et al. Randomized, double-blind trial of guanfacine extended release in children with attentiondeficit/hyperactivity disorder: Morning or evening administration. J Am Acad Child Adolesc Psychiatry 2013; 52: 921-30. https://doi.org/10.1016/j.jaac.2013.06.006
Wilens TE, McBurnett K, Turnbow J, Rugino T, White C, Youcha S. Morning and evening effects of guanfacine extended release adjunctive to psychostimulants in pediatric ADHD: Results from a phase III multicenter trial. J Atten Disord 2017; 21: 110-19. https://doi.org/10.1177/1087054713500144
Handen BL, Sahl R, Hardan AY. Guanfacine in children with autism and/or intellectual disabilities. J Dev Behav Pediatr 2008; 29: 303-8. https://doi.org/10.1097/DBP.0b013e3181739b9d
Jaselskis CA, Cook EH, Fletcher KE, Leventhal BL. Clonidine treatment of hyperactive and impulsive children with autistic disorder. J Clin Psychopharmacol 1992; 12: 322-6. https://doi.org/10.1097/00004714-199210000-00005
Scahill L, McCracken JT, King BH, Rockhill C, Shah B, Politte L, et al. Extended-release guanfacine for hyperactivity in children with autism spectrum disorder. Am J Psychiatry 2015; 172: 1197-206. https://doi.org/10.1176/appi.ajp.2015.15010055
Baweja R, Mattison RE, Waxmonsky JG. Impact of attentiondeficit hyperactivity disorder on school performance: What are the effects of medication? Pediatr Drugs 2015; 17: 459- 77. https://doi.org/10.1007/s40272-015-0144-2
Evans SW, Pelham WE, Smith BH, Bukstein O, Gnagy EM, Greiner AR, et al. Dose- response effects of methylphenidate on ecologically valid measures of academic performance and classroom behavior in adolescents with ADHD. Experim Clin Psychopharmacol 2001; 9: 163-75. https://doi.org/10.1037/1064-1297.9.2.163
Kavale K. The efficacy of stimulant drug treatment for hyperactivity: A meta-analysis. J Learn Disabil 1982; 15: 280- 9. https://doi.org/10.1177/002221948201500508
Gillberg C, Melander H, von Knorring A-L, Janols L-O, Thernlund G, Hagglof B, et al. Long-term stimulant treatment of children with attention-deficit hyperactivity disorder symptoms. Arch Gen Psychiatry 1997; 54: 857-64. https://doi.org/10.1001/archpsyc.1997.01830210105014
Aman MG, Bukstein OG, Gadow KD, Arnold LG, Molina BSG, McNamara N, et al. What does risperidone add to parent training and stimulant for severe aggression in child attention- deficit/hyperactivity disorder? J Am Acad Child Adolesc Psychiatry 2014; 53: 47-60. https://doi.org/10.1016/j.jaac.2013.09.022
McCracken JT, McGough J, Shah B, Cronin P, Hong D, Aman MG, et al. Risperidone in children with autism and serious behavioral problems. New Eng J Med 2002; 347: 314-21. https://doi.org/10.1056/NEJMoa013171
Pandina GJ, Bossie CA, Youssef E, Zhu Y, Dunbar F. Risperidone improves behavioral symptoms in children with autism in a randomized, double-blind, placebo-controlled trial. J Autism Dev Disord 2007; 37: 367-73. https://doi.org/10.1007/s10803-006-0234-7
Politte C, Scahill L, Figueroa J, McCracken JT, King B, McDougle CJ. A randomized, placebo-controlled trial of extended-release guanfacine in children with autism spectrum disorder and ADHD symptoms: An analysis of secondary outcome measures. Neuropsychopharmacol 2018; 43: 1772-8. https://doi.org/10.1038/s41386-018-0039-3
de la Cruz LF, Simonoff E, McGough JJ, Halperin JM, Arnold E, Stringaris A. Treatment of children with attentiondeficit/hyperactivity disorder (ADHD) and irritability: Results from the multimodal treatment study of children with ADHD(MTA). J Am Acad Child Adolesc Psychiatry 2015; 54: 62-70. https://doi.org/10.1016/j.jaac.2014.10.006
Ghanizadeh A, Ayoobzadehshirazi A. A randomized doubleblind placebo-controlled clinical trial of adjuvant buspirone for irritability in autism. Pediatr Neurol 2015; 52: 77-81. https://doi.org/10.1016/j.pediatrneurol.2014.09.017
McDougle CJ, Scahill L, Aman MG, McCracken JT, Tierney E, Davies M, et al. Risperidone for the core symptom domains of autism: Results from the study by the autism network of the research units on pediatric psychopharmacology. Am J Psychiatry 2005; 162: 1142-8. https://doi.org/10.1176/appi.ajp.162.6.1142
Owen R, Sikich L, Marcus RN, Corey-Lisle P, Manos G, McQuade RD. Aripiprazole in the treatment of irritability in children and adolescents with autistic disorder. Pediatrics 2011; 124: 1533-40. https://doi.org/10.1542/peds.2008-3782
King BH, Hollander E, Sikich L, McCracken JT, Scahill L, Bregman JD. Lack of efficacy of citalopram in children with autism spectrum disorders and high levels of repetitive behavior. Arch Gen Psychiatry 2009; 66: 583-90. https://doi.org/10.1001/archgenpsychiatry.2009.30
Arnold LE, Gadow KD, Farmer CA, Findling RL, Bukstein O, Molina BSG. Comorbid anxiety and social avoidance in treatment of severe childhood aggression: Response to adding risperidone to stimulant and parent training; mediation of disruptive symptom response. J Child Adolesc Psychopharmacol 2015; 25: 203-12. https://doi.org/10.1089/cap.2014.0104
Joshi G, Faraone SV, Wozniak J, Tarko L, Fried R, Galdo M, et al. Symptom profiles of ADHD in youth with highfunctioning autism spectrum disorder: A comparative study in psychiatrically referred populations J Atten Disord 2017; 21: 846-55. https://doi.org/10.1177/1087054714543368
Mayes SD, Calhoun SL, Mayes RD, Molitoris S. Autism and ADHD: Overlapping and discriminating symptoms. Res Autism Spectr Disord 2012; 6: 277-85. https://doi.org/10.1016/j.rasd.2011.05.009
Biederman J, Faraone SV, Milberger S, Jetton JG, Chen L, Mick E, et al. Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder? Findings from a four-year follow-up study of children with ADHD. J Am Acad Child Adolesc Psychiatry 1996; 35: 1193-1204. https://doi.org/10.1097/00004583-199609000-00017
Efron D, Scriberras E. The diagnostic outcome of children with suspected attention hyperactivity disorder following multidisciplinary assessment. J Paediatr Child Health 2010; 46: 392-7. https://doi.org/10.1111/j.1440-1754.2010.01750.x
Faraone V, Biederman J, Weber W, Russell RL. Psychiatric, neuropsychological, and psychosocial features of DSM-IV subtypes of attention-deficit/hyperactivity disorder: Results from a clinically referred sample. Psychol Med 1998; 36: 159- 65. https://doi.org/10.1017/S003329170500471X
King S, Waschbusch DA. Aggression in children with attention-deficit/hyperactivity disorder. Expert Rev Neurother 2010; 10: 1581-94. https://doi.org/10.1586/ern.10.146
Mayes SD, Waxmonsky J, Calhoun SL, Kokotovich C, Mathiowetz C, Baweja R. Disruptive mood dysregulation disorder (DMDD) symptoms in children with autism, ADHD, and neurotypical development and impact of co-occurring ODD, depression, and anxiety. Res Autism Spectr Disord 2015; 18: 64-72. https://doi.org/10.1016/j.rasd.2015.07.003
Mayes SD, Calhoun SL, Murray MJ, Ahuja M, Smith LA. Anxiety, depression, and irritability in children with autism relative to children with other neuropsychiatric disorders and typical development. Res Autism Spectr Disord 2011; 5: 474- 85. https://doi.org/10.1016/j.rasd.2010.06.012
Hauck TS, Lau C, Wing LLF, Kurdyak P, Tu K. ADHD treatment in primary care: Demographic factors, medication trends, and treatment predictors. Canadian J Psychiatry 2017; 62: 393-402. https://doi.org/10.1177/0706743716689055
Wolraich ML, Lindgren S, Stromquist A, Milich R, Davis C, Watson D. Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder. Pediatrics 1990; 86: 95-101.
Zito JM, Safer DJ, dosReis S, Magder LS, Gardner JF, Zarin DA. Psychotherapeutic medication patterns for youths with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med 1999; 153: 1257-63. https://doi.org/10.1001/archpedi.153.12.1257
Aman MG, Lam KSL, Van Bourgondien ME. Medication patterns in patients with autism: Temporal, regional, and demographic influences. J Child Adolesc Psychopharmacol 2005; 15: 116-26. https://doi.org/10.1089/cap.2005.15.116
Coury DL, Anagnostou E, Manning-Courtney P, Reynolds A, Cole L, McCoy R, et al. Use of psychotropic medication in children and adolescent with autism spectrum disorders. Pediatrics 2012; 130: S69-76. https://doi.org/10.1542/peds.2012-0900D
Frazier TW, Shattuck PT, Narendorf SC, Cooper BP, Wagner M, Spitznagel EL. Prevalence and correlates of psychotropic medication use in adolescents with an autism spectrum disorder with and without caregiver-reported attentiondeficit/hyperactivity disorder. J Child Adolesc Psychopharmacol 2011; 21: 571-9. https://doi.org/10.1089/cap.2011.0057
Logan SL, Carpenter L, Leslie S, Garrett-Mayer E, Hunt KJ, Charles J, et al. Aberrant behaviors and co-occurring conditions as predictors of psychotropic polypharmacy among children with autism spectrum disorders. J Child Adolesc Psychopharmacol 2015; 25: 323-36. https://doi.org/10.1089/cap.2013.0119
Madden JM, Lakoma MD, Lynch FL, Rusinak D, Owen-Smith AA, Coleman K, et al. Psychotropic medication use among insured children with autism spectrum disorder. J Autism Dev Disord 2017; 47: 144-54. https://doi.org/10.1007/s10803-016-2946-7
Mandell DS, Morales KH, Marcus SC, Stahmer AC, Doshi J, Polsky DE. Psychotropic medication use among Medicaidenrolled children with autism spectrum disorders. Pediatrics 2008; 121: e441-8. https://doi.org/10.1542/peds.2007-0984
Martin A, Scahill L, Klin A, Volkmar FR. Higher-functioning pervasive developmental disorders: Rates and patterns of psychotropic drug use. J Am Acad Child Adolesc Psychiatry 1999; 38: 923-31. https://doi.org/10.1097/00004583-199907000-00024
Oswald DP, Sonenklar NA. Medication use among children with autism spectrum disorders. J Child Adolesc Psychopharmacol 2007; 17: 348-55. https://doi.org/10.1089/cap.2006.17303
Rosenberg RE, Mandell DS, Farmer JE, Law JK, Marvin AR, Law PA. Psychotropic medication use among children with autism spectrum disorders enrolled in a national registry, 2007-2008. J Autism Dev Disord 2010; 40: 342-51. https://doi.org/10.1007/s10803-009-0878-1
Schubert JR, Camacho F, Leslie D. Psychotropic medication trends among children and adolescents with autism spectrum disorder in the Medicaid program. Autism 2014; 18: 631-7. https://doi.org/10.1177/1362361313497537
Spencer D, Marshall J, Post B, Kulakodlu M, Newschaffer C, Dennen T, et al. Psychotropic medication use and polypharmacy in children with autism spectrum disorders. Pediatrics 2013; 132: 833-40. https://doi.org/10.1542/peds.2012-3774
Kamble P, Chen H, Johnson ML, Bhatara V, Aparasu RR. Concurrent use of stimulants and second-generation antipsychotics among children with ADHD enrolled in Medicaid. Psychiatr Services 2015; 66: 404-10. https://doi.org/10.1176/appi.ps.201300391
Sultan RS, Wang S, Crystal S, Olfson M. Antipsychotic treatment among youths with attention-deficit/hyperactivity disorder. JAMA Network Open 2019. https://doi.org/10.1001/jamanetworkopen.2019.7850
Zito JM, Safer DJ, dosReis S, Gardner JF, Magder L, Soeken K, et al. Psychotropic practice patterns for youth: A 10-year perspective. Archives of Ped Adolescent Med 2003; 157: 17- 25. https://doi.org/10.1001/archpedi.157.1.17
Kamimura-Nishimura KI, Epstein JN, Froehlich TE, Peugh J, Brinkman WB, Baum R, et al. Factors associated with attention deficit hyperactivity disorder medication use in community care settings. J Pediatrics In press.
Sawyer MG, Rey JM, Graetz BW, Clark JT, Baghurst PA. Use of medication by young people with attentiondeficit/hyperactivity disorder. Med J Australia 2002; 177: 21- 5. https://doi.org/10.5694/j.1326-5377.2002.tb04624.x
Burcu M, Safer DJ, Zito JM. Antipsychotic prescribing for behavioral disorders in US youth: Physician specialty, insurance coverage, and complex regimens. Pharmacoepidemiol Drug Safety 2016; 25: 26-34. https://doi.org/10.1002/pds.3897
Cox ER, Motheral BR, Henderson RR, Mager D. Geographic variation in the prevalence of stimulant medication use among children 5 to 14 years old: Results from a commercially insured US sample. Pediatrics 2003; 111: 237- 43. https://doi.org/10.1542/peds.111.2.237
Clark T, Feehan C, Tinline C, Vostanis P. Autistic symptoms in children with attention deficit-hyperactivity disorder. Eur Child Adolesc Psychiatry 1999; 8: 50-5. https://doi.org/10.1007/s007870050083
Miodovnik A, Harstad E, Sideridis G, Huntington N. Timing of the diagnosis of attention-deficit/hyperactivity disorder and autism spectrum disorder. Pediatrics 2015; 136: 830-7. https://doi.org/10.1542/peds.2015-1502
Connor DF, Steeber J, McBurnett K. A review of attentiondeficit/hyperactivity disorder complicated by symptoms of oppositional defiant disorder or conduct disorder. J Dev Behav Pediatrics 2010; 31: 427-40. https://doi.org/10.1097/DBP.0b013e3181e121bd
Mayes SD, Calhoun SL, Aggarwal R, Baker C, Mathapati S, Anderson R. Explosive, oppositional, and aggressive behavior in children with autism compared to other clinical disorders and typical development. Res Autism Spectr Disord 2012; 6: 1-10. https://doi.org/10.1016/j.rasd.2011.08.001
Lindgren SD, Koeppl GK. Assessing child behavior problems in a medical setting: Development of the Pediatric Behavior Scale. In RJ Prinz, editor. Advances in behavioral assessment of children and families. Greenwich, CT: JAI 1987; pp. 57-90.
Mayes SD. Checklist for Autism Spectrum Disorder. Wood Dale, IL: Stoelting. 2012. https://doi.org/10.1037/t03996-000
Mayes SD, Calhoun SL, Waschbusch D, Baweja R. Autism and reactive attachment/disinhibited social engagement disorders: Co-occurrence and differentiation. Clin Child Psychol Psychiatry 2017; 22: 620-31. https://doi.org/10.1177/1359104516678039
Tierney C, Mayes SD, Lohs SR, Black A, Gisin E, Veglia M. How valid is the Checklist for Autism Spectrum Disorder when a child has apraxia of speech? J Dev Behav Pediatr 2015; 36: 569-74. https://doi.org/10.1097/DBP.0000000000000189
Mayes SD, Calhoun SL, Murray MJ, Morrow JD, Yurich KKL, Mahr, F, et al. Comparison of scores on the Checklist for Autism Spectrum Disorder, Childhood Autism Rating Scale (CARS), and Gilliam Asperger’s Disorder Scale (GADS) for children with low functioning autism, high functioning autism or Asperger’s disorder, ADHD, and typical development. J Autism Dev Disord 2009; 39: 1682-93. https://doi.org/10.1007/s10803-009-0812-6
Murray MJ, Mayes SD, Smith LA. Brief report: Excellent agreement between two brief autism scales (Checklist for Autism Spectrum Disorder and Social Responsiveness Scale) completed independently by parents and the Autism Diagnostic Interview-Revised. J Autism Dev Disord 2011; 41: 1586-90. https://doi.org/10.1007/s10803-011-1178-0
Bixler EO, Vgontzas AN, Lin H-M, Calhoun S, Vela-Bueno A, Fedok F, et al. Sleep disordered breathing in children in a general population sample: Prevalence and risk factors. Sleep 2009; 32: 731-6. https://doi.org/10.1093/sleep/32.6.731
Mayes SD, Gordon M, Calhoun SL, Bixler EO. Long-term temporal stability of measured inattention and impulsivity in typical and referred children. J Atten Disord 2014; 18: 23-30. https://doi.org/10.1177/1087054712448961
Conrad AL, Richman L, Lindgren S, Nopoulos P. Biological and environmental predictors of behavioral sequelae in children born preterm. Pediatrics 2010; 125: e83-9. https://doi.org/10.1542/peds.2009-0634
Waxmonsky J, Mayes SD, Calhoun SL, Fernandez-Mendoza J, Waschbusch D, Bixler EO. The association between disruptive mood dysregulation disorder symptoms and sleep problems in children with and without ADHD. Sleep Med 2017; 37: 180-6. https://doi.org/10.1016/j.sleep.2017.02.006
Burke JD, Boylan K, Rowe R, Duku E, Stepp SD, Hipwell AE, et al. Identifying the irritability dimension of ODD: Application of a modified bifactor model across five large community samples of children. J Abnorm Psychol 2014; 123: 841-51. https://doi.org/10.1037/a0037898
Waschbusch D, Baweja R, Babinski D, Mayes SD, Waxmonsky J. Irritability and limited prosocial emotions/callous-unemotional traits in elementary school age children. Behav Therapy 2019. https://doi.org/10.1016/j.beth.2019.06.007
Costello EJ, Copeland W, Angold A. Trends in psychopathology across the adolescent years: What changes when children become adolescents, and when adolescents become adults? J Child Psychol Psychiatry 2011; 52: 1015-25. https://doi.org/10.1111/j.1469-7610.2011.02446.x
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005; 62: 593-602. https://doi.org/10.1001/archpsyc.62.6.593
Shaywitz S, Shaywitz B, Wietecha L, Wigel S, McBurnett K, Williams D, et al. Effect of atomoxetine treatment on reading and phonological skills in children with dyslexia or attentiondeficit/hyperactivity disorder and comorbid dyslexia in a randomized, placebo-controlled trial. J Child Adolesc Psychopharmacol 2017; 27: 19-28. https://doi.org/10.1089/cap.2015.0189
Mayes SD, Calhoun SL. Frequency of reading, math, and writing disabilities in children with clinical disorders. Learn Individ Differences 2006; 16: 145-57. https://doi.org/10.1016/j.lindif.2005.07.004
Waschbusch DA, Cunningham CE, Pelham WE, Rimas HL, Greiner AR, Gnagy EM, et al. A discrete choice conjoint experiment to evaluate parent preferences for treatment of young, medication naïve children with ADHD. J Clin Child Adolesc Psychol 2011; 40: 546-61. https://doi.org/10.1080/15374416.2011.581617
Fremont WP, Nastasi R, Newman N, Roizen NJ. Comfort level of pediatricians and family medicine physicians diagnosing and treating child and adolescent psychiatric disorders. Internat J Psychiatry Med 2008; 38: 153-68. https://doi.org/10.2190/PM.38.2.c
Panerai S, Suraniti GS, Catania V, Zingale M, Ferri R, Raggi A, et al. (2019): Early results from a combined low-intensive psychoeducational intervention for preschoolers with autism spectrum disorder. Disabil Rehabil 2019. https://doi.org/10.1080/09638288.2018.1522553
Eldevik S, Hastings RP, Hughes JC, Jahr E, Eikeseth S, Cross S. Meta-analysis of early intensive behavioral intervention for children with autism. J Clin Child Adolesc Psychol 2009; 38: 439-50. https://doi.org/10.1080/15374410902851739
