Attention deficit hyperactivity disorder management is evidence-based practice with steady efficacy of treatment for ADHD. The American Academy of Pediatrics recommends a different treatment paradigm depending on the age of the person being treated. For those aged 4-5 years, the Academy recommends evidence-based parent and/or teacher behavioral therapy, with additional methylphenidate only when there is moderate to severe functional disturbance. For those aged 6-11 years, the use of drugs in combination with behavioral therapy is recommended, with evidence for stronger stimulant drugs than that for other classes. For those aged 12-18, medications should be prescribed with the consent of treated adolescents, preferably combined with behavioral therapy. Evidence for the usefulness of behavioral interventions in this age group is only assessed "C" quality, however.
There are a number of stimulant and non-stimulant medications that are indicated for the treatment of ADHD. The most commonly used stimulant drugs include methylphenidate (Ritalin, Concerta), mixed amphetamine salts (Adderall, Mydayis), dextroamphetamine (Dexedrine), and lisdexamfetamine (Vyvanse). Non-stimulant drugs with specific indications for ADHD include atomoxetine (Strattera), guanfacine (Intuniv), and clonidine (Kapvay). Other drugs that may be prescribed off-label include bupropion (Wellbutrin), tricyclic antidepressants, SNRI, or MAOI. The presence of co-happening disorders can make finding the right treatment and diagnosis far more complicated, costly, and time-consuming. So it is advisable to assess and simultaneously treat any comorbid disorders.
Various psychotherapeutic and behavioral modification approaches to managing ADHD including psychotherapy and memory training work can be used. Improving the surrounding home and school environments with parental management training and classroom management can improve the behavior of children with ADHD. ADHD special trainers provide services and strategies to improve functionality, such as time management or organizational advice. The self-control training program has been shown to have limited effectiveness.
In 2006 there was a lack of data on the potential adverse effects of ADHD drugs, with very few studies assessing the safety or efficacy of treatment beyond four months, and no randomized controlled trials assessing for a period of use over two years.
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There are various psychotherapy approaches used by psychologists and psychiatrists; which is used depends on the patient and the patient's symptoms. Approaches include psychotherapy, cognitive behavioral therapy, support groups, parenting training, meditation, and social skills training.
Parents education and classroom management
Improving the neighborhood and surrounding schools can improve the behavior of children with ADHD. Parents of children with ADHD often show similar deficits, and thus may not be enough to help a child with difficulty. Improving parental understanding of children's behavior and teaching them strategies to improve function and communication and prevent undesirable behavior have a measurable effect on children with ADHD. Different educational interventions for parents together are called Parenting Training. Techniques include operant conditioning: consistent reward apps to meet good goals and behaviors (positive reinforcement) and punishments such as time-out or dismissal of privileges for failing to meet goals or bad behavior. Classroom management is similar to parent management training; educators learn about ADHD and techniques to improve behavior applied to classroom settings. The strategies used include improvements to classroom activity, daily feedback, and token economics.
Cognitive training
A 2013 paper published by two researchers from the University of Oslo concluded that working memory training provides short-term improvement, but that there is limited evidence that these improvements are maintained or that they are generalizable to improve verbal skills, math skills, attention, or word decoding. A 2014 paper published by a group of researchers from the University of Southampton presented the results of a meta-analysis study of 14 recently-published randomized controlled trials (RCTs). The authors conclude that "more evidence of blinded research is needed before cognitive training can be supported as front-line treatment of core ADHD symptoms".
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Drugs
History
The first reported evidence of stimulant drugs used to treat children with concentration and hyperactivity problems occurred in 1937. Charles Bradley in Providence, Rhode Island reported that a group of children with behavioral problems improved after being treated with Benzedrine stimulants. In 1954, methylphenidate stimulants (Ritalin, first produced in 1944) became available; remains one of the most widely prescribed drugs for ADHD. Initially the drug was used to treat narcolepsy, chronic fatigue, depression, and to counteract other sedative drug effects. The drug began to be used for ADHD in the 1960s and continued to increase use.
In 1975, pemoline (Cylert) was approved by the US FDA for use in the treatment of ADHD. While an effective agent for managing symptoms, the development of liver failure in 14 cases over the next 27 years will result in manufacturers pulling this drug off the market. New drug delivery systems were discovered in 1999 that eliminated the need for multiple doses throughout the day or took medication at school. This new system includes drug pellets coated with various time-releasing agents to allow drugs to dissolve per hour over a period of 8-12 hours (Metadate CD, Adderall XR, Focalin XR) and osmotic pumps that exhale the liquid methylfenidate mud across 8-12 hours period after consumption (Concerta).
In 2003, atomoxetine (Strattera) received the first FDA approval for nonstimulant drugs to be used specifically for ADHD. In 2007, lisdexamfetamine (Vyvanse) became the first prodrug for ADHD to receive FDA approval.
Stimulants
Stimulants are the most commonly prescribed medication for ADHD. The stimulant drugs indicated for treating ADHD are methylphenidate (Ritalin, Concerta), dexmethylphenidate (Focalin), mixed amphetamine salts (Adderall), dextroamphetamine (Dexedrine), lisdexamfetamine (Vyvanse), and in rare cases methamphetamine (Desoxyn). Remedy controlled drugs can allow once-daily medication in the morning. This is very helpful for children who do not like taking medication in the middle of school day. Some controlled release methods are used.
The stimulants used to treat ADHD increase the extracellular concentration of dopamine and norepinephrine neurotransmitters, which improves cellular communication between neurons utilizing this compound. The therapeutic benefits are due to noradrenergic effects on the coeruleus locus and the effects of the prefrontal and dopaminergic cortices in the ventral tegmental area, nucleus accumbens, and the prefrontal cortex.
Stimulant drugs are considered safe when used under medical supervision. Nevertheless, there are concerns that the long-term safety of these drugs has not been adequately documented, as well as the social and ethical issues concerning their use and dispensation. The US FDA has added black-box warnings to some ADHD medications, warning that abuse may cause psychotic episodes, psychological dependence, and severe depression can occur during withdrawal from rough use.
Stimulants are the most effective drugs available for the treatment of ADHD. Seven different stimulant formulations have been approved by the US Food and Drug Administration (FDA) for the treatment of ADHD: four amphetamine-based formulations, two methylphenidate-based formulations, and dextromethamphetamine hydrochloride. Atomoxetine, guanfacine and clonidine are the only non-controlled, non-stimulant drugs approved by the FDA for the treatment of ADHD.
Short-term clinical trials have shown an effective drug to treat ADHD, but trials usually use exclusion criteria, which means that drug knowledge for ADHD is based on a fraction of patients commonly seen in clinical practice. They have not been found to improve school performance and less data on long-term effectiveness and severity of side-effects. Stimulants, however, may reduce the risk of unintentional injury in children with ADHD.
This class of drugs is generally regarded as a unit; However, they affect the brain differently. Some investigations are dedicated to finding commonalities of children who respond to certain medications. The behavioral response to stimulants in children is the same regardless of whether they have ADHD or not.
Drug stimulants are an effective treatment for attention-deficit adult hyperactivity disorder although response rates may be lower for adults than for children. Some doctors may recommend antidepressant drugs as first-line treatment rather than stimulants although antidepressants have a much lower treatment effect size than stimulant drugs.
Amphetamine
Amphetamine is a chiral compound consisting of two isomers: levoamphetamine and dextroamphetamine. Levoamphetamine and dextroamphetamine have the same chemical formula but are mirror images of one another, just like the same one's hand but are mirror images of one another. These mirror differences are sufficient to produce small differences in their pharmacological properties; levoamphetamine has a slightly longer half-life than dextroamphetamine, but dextroamphetamine is a more potent central nervous system stimulant. Although effective in reducing primary ADHD symptoms such as hyperactivity and lack of attention, many adverse side effects are presented. These include headaches, anxiety, nausea and insomnia.
Five different amphetamine-based medications are currently used in the treatment of ADHD: rasemic amphetamine, dextroamphetamine, lisdexamfetamine, and two mixed enantiomer products (Adderall and Dyanavel XR). Lisdexamfetamine is an inactive prodrug of dextroamphetamine (ie, lisdexamfetamine itself does nothing in the body, but metabolizes into dextroamphetamine). Adderall is a proprietary mixture (75%) dextroamphetamine and (25%) levoamphetamine, which results in a very mild difference between the effects. Dyanavel XR contains a similar mixture. Adderall began to work before dextroamphetamine due to levoamphetamine. Levoamphetamine also provides Adderall with a longer clinical effect than dextroamphetamine. Some children with ADHD and comorbid disorders respond well to levoamphetamine.
Methamphetamine
The body metabolizes methamphetamines into amphetamines (other than less-active metabolites). A quarter of methamphetamine will eventually become amphetamine. After comparing only the similarities between dextroamphetamine and dextromethamphetamine, the latter is said to be a stronger stimulant.
Methylphenidate
Like amphetamine, methylphenidate (MPH) is a chiral compound consisting of two isomers: d-threo-methylphenidate (also known as dexmethylphenidate, d-methylphenidate, or d-MPH) and l-threo-methylphenidate (also known as l-methylphenidate or l-MPH). Both isomers have the same chemical formula but are mirror images of each other, just like the same one's hands but are mirror images of one another. Unlike amphetamines, the difference in pharmacological properties between d-MPH and l-MPH is significant, since l-MPH is clearly lower than d-MPH in effect, caused by a number of major differences between isomers.
There are two main drugs derived from the isomer of methylphenidate: a half-dre-threo-methylphenidate and half l-threo-methylphenidate mixture called methylphenidate (Ritalin, Concerta), and an enantiopure formulation containing only d-threo-methylphenidate called dexmethylphenidate (Focalin).
Non-stimulant
Atomoxetine (Strattera), guanfacine (Intuniv), and clonidine (Kapvay) are drugs approved for the treatment of ADHD that has been classified as "non-stimulant".
- Atomoxetine (Strattera)
- Atomoxetine is less effective than stimulants for ADHD, is associated with cases of rare liver damage, and carries the US FDA's black box of warning about the idea of ​​suicide. Controlled studies show an increase in heart rate, weight loss, decreased appetite, and nausea that comes with treatment.
- Guanfacine (Intuniv)
- Extended release forms have been approved by the FDA for the treatment of attention-deficit hyperactivity disorder (ADHD) in children as an alternative to stimulant drugs. His favorable action is likely due to his ability to reinforce prefrontal cortical settings and behavior.
- Clonidine (Kapvay)
- An? 2A adrenergic receptor agonist has also been approved in the US. Clonidine was originally developed as a treatment for high blood pressure. Low doses at night and/or afternoon are sometimes used along with stimulants to help sleep and because clonidine sometimes helps in moderate impulsive and oppositional behaviors and can reduce tics. It may be more useful for Tourette's comorbid syndrome.
More
Some medications used to treat ADHD are prescribed off-label, beyond the scope of FDA-approved indications for various reasons. The US FDA requires two clinical trials to prove the safety and efficacy of potential drugs in treating ADHD. The drugs below have not been tested, so its efficacy is not proven (but this drug has been licensed for other indications, so it has been shown to be safe in that population), but the exact dosage and instructional use are not highly characterized.
- Bupropion (Wellbutrin)
- Bupropion is classified as an atypical antidepressant. This is the most common off-label prescription for ADHD. This inhibits the reuptake of norepinephrine, and to a lesser extent, dopamine, in synapses of nerves, and has little to no effect on serotonergic reuptake. Bupropion is not a controlled substance. It is commonly prescribed as a timed release formulation to reduce the risk of side effects.
- Modafinil (Provigil, Alertec)
- Awareness-raising agents that operate primarily as selective, relatively weak, atypical dopamine reuptake inhibitors. Double-blind randomized controlled trials have demonstrated the efficacy and tolerability of modafinil in ADHD in children, but there is a risk of serious side effects such as skin and modafinil reactions not recommended for use in children. In the United States, it was initially awaiting marketing on the label as Sparlon, but approval was rejected by the FDA because of the great concern over the occurrence of Stevens-Johnson Syndrome in clinical trials.
Other drugs that may be prescribed off-label include certain antidepressants such as tricyclic antidepressants (TCA), SNRI, SSRI, or MAOI.
Antipsychotic drugs
Atypical antipsychotic drugs, which are approved for the treatment of certain behavioral disorders, are sometimes prescribed off-label as combination therapy with stimulants for comorbid treatment (ie, co-occurring disease) of ADHD and disruptive behavioral disorders. Canada's clinical practice guidelines only support the use of dopaminergic antipsychotics with the selectivity of D2-type dopamine receptors, especially risperidone, as a third-line treatment for both disorders after the failure of stimulant monotherapy and psychosocial intervention. The combined use of D2-type receptor antagonists and ADHD stimulants for the treatment of ADHD with comorbid behavior disorder does not seem to have far worse side effects than ADHD stimulants or antipsychotic monotherapy. Research shows, but has not been confirmed, the efficacy of combination antipsychotic treatment and stimulants for both disorders; it is not clear whether combination therapy for both disorders is superior to stimulant or antipsychotic monotherapy. There is no evidence to support the use of an antipsychotic subclass for the treatment of ADHD core symptoms (ie, lack of attention and hyperactivity) without comorbid behavior disorders.
Dopaminergic antipsychotics affect dopamine neurons by binding to postsynaptic dopamine receptors, where they function as receptor antagonists; In contrast, ADHD stimulants are indirectly anonymous postsynaptic dopamine receptors; in other words, this stimulant increases the level of synaptic dopamine which then binds to the post-adaptin receptor. Stimulants increase the concentration of synaptic dopamine by activating certain presinaptic receptors (ie TAAR1) or by blocking or altering the function of the reuptake transporter (eg, DAT, VMAT2) in presinaptic neurons.
Comparative efficacy, tolerability, and setting status
Concerns about stimulants
Some parents and professionals have been asking questions about drug side effects and their long-term use.
Increase usage
Outpatient treatment rates have stabilized in the US recently. Prior to this, outpatient treatment for ADHD in the US grew from 0.9 children per 100 in 1987 to 3.4 per 100 in 1997. A survey conducted by the Centers for Disease Control and Prevention in 2011-2012 found 11% children between the ages of 4 and 17 reported having received a diagnosis of ADHD health care providers at some point (15% boys and 7% girls), a 16% increase since 2007 and a 41% increase over the past decade. The CDC notes that community samples show the incidence of ADHD in American children is higher than the five percent stated by the American Psychiatric Association at DSM-5, with 8.8% of US children who have the current diagnosis in the 2011 survey. However, only 6.1% of children in the 2011 survey took ADHD medication, showing as many as 17.5% of children with ADHD are currently not receiving treatment.
Use in preschool
Parents of children with ADHD note that they usually show their symptoms at an early age. There are several longitudinal studies on the long-term effects of using stimulants in children. The use of stimulant drugs has not been approved by the FDA for children under the age of six. A growing trend is the diagnosis of younger children with ADHD. Prescriptions for children under 5 years rose almost 50 percent from 2000 to 2003. Research on this issue suggests that stimulant drugs can help children with "severe ADHD symptoms" but usually at lower doses than older children old. It was also found that children at this age are more sensitive to side effects and should be closely monitored. Evidence suggests that careful assessment and highly individualized behavioral interventions significantly improve social and academic skills, while medications only treat symptoms of disorder. "One of the main reasons cited for the growing use of psychotropic interventions is that many doctors are aware that psychological intervention is expensive and difficult to maintain."
Side effects
Delay growth and weight loss
There is some evidence of a mild reduction in growth rates with prolonged stimulant treatment in children, but no causal association has been established and the reduction does not seem to last long. Weight loss is almost always consistent with loss of appetite, which may be due to medication. Losing weight is very rare. Loss of appetite is temporary and usually returns as a daily effect of stimulating thirst. Nausea, dizziness, and headaches, other side effects, can also indirectly affect appetite and lead to weight loss.
Cardiovascular side effects
There are concerns that stimulants and atomoxetine, which increase heart rate and blood pressure, can cause serious cardiovascular problems. A very recent large-scale study by the FDA shows that, in children, young adults and adults, there is no association between serious serious cardiovascular events (sudden death, myocardial infarction, and stroke) and medical use of amphetamines, methylphenidate, or other ADHD stimulants.
Psychiatric side effects
Many of these drugs are associated with physical and psychological dependence. Sleep problems can occur.
Methylphenidate may exacerbate psychosis in psychotic patients, and in very rare cases it has been associated with the emergence of new psychotic symptoms. It should be used with extreme caution in patients with bipolar disorder due to potential induction of mania or hypomania. There is a very rare report about the idea of ​​suicide, but the evidence does not support the connection. Long-term effects on mental health disorders later in the day of chronic use of methylphenidate are unknown.
A 2009 FDA review of 49 clinical trials found that about 1.5% of children in clinical trials of drugs for ADHD have experienced signs or symptoms of psychosis or mania. The post-sale report is also analyzed, with almost half involving children under the age of eleven. Approximately 90% of cases do not have a history of previous similar psychiatric events. Hallucinations involving snakes, worms or insects are the most commonly reported symptoms.
Long-term use
Exposure to long-term methylphenidate or amphetamine in some species is known to result in the development of abnormal dopamine systems or nerve damage, but humans develop normal development and nerve growth. Magnetic resonance imaging studies show that long-term treatment with amphetamine or methylphenidate decreases abnormalities in brain structure and function found in subjects with ADHD, and improves the function of the right caudate nucleus.
Research reviews of clinical stimulants have established the safety and effectiveness of long-term use of amphetamine for ADHD. A controlled trial that spans two years has demonstrated the effectiveness and safety of ongoing treatment. One review highlights 9 months of randomized controlled trials of amphetamine in children who found an average increase of 4.5 IQ points and continued improvement in attention, disruptive behavior, and hyperactivity.
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Tolerance to the effects of stimulant therapy may occur, and rebound symptoms may occur when the dose is exhausted. The rebound effect is often the result of too high a stimulant dose or the individual can not tolerate the stimulant drug. Signs that the stimulant dose is too high include irritability, feelings of stimulation or dulling of influence and personality.
Stimulant withdrawal or rebound reaction can occur and can be minimized in intensity through phased reduction of drugs for several weeks or months. A small study of sudden stimulant withdrawal does indicate that withdrawal reactions are not typical, and can only occur in susceptible individuals.
Cancer
Concerns about chromosomal aberrations and possible future cancer were raised by small-scale studies on methylphenidate use, although a review by the Food and Drug Administration (FDA) found a significant methodological problem with the study. A follow-up study conducted with improved methodology found no evidence that methylphenidate can cause cancer, stating "concerns about the potential increased risk of developing cancer later in life after long-term MPH treatment is not supported."
Cost effectiveness
Combined medical management and behavioral care are the most effective ADHD management strategies, followed by treatment only, and then behavioral care. In terms of cost effectiveness, management with drugs has proven to be the most cost-effective, followed by behavioral care, and combined treatment. The most effective and efficient way individually is with stimulant drugs. In addition, long-acting medications for ADHD, compared with shorter work varieties, generally appear to be cost-effective. Comorbid (associated with two diseases occurring together, eg depression and ADHD) disorders makes finding the right treatment and diagnosis much more expensive than when comorbid disorders do not exist.
Alternative medicine
Most alternative therapies do not have sufficient supporting evidence to recommend it. In addition, when only the best studies performed the calculated results were likely to be similar to placebo.
Neurofeedback
Neurofeedback (NF) or EEG biofeedback is a treatment strategy used for children, adolescents and adults with ADHD. The human brain emits electrical energy as measured by electrodes. Neurofeedback tells the patient when there is a beta wave. This theory believes that those with ADHD can train themselves to reduce the symptoms of ADHD.
No serious adverse effects of neurofeedback were reported. Research on neurofeedback is mostly limited and of poor quality. Although there are some indications on the effectiveness of biofeedback not conclusive: some studies have yielded positive results, but the best ones designed have shown a reduced or non-existent effect. In general, no effect was found on the most blind measurements of ADHD, which may indicate that a positive result was due to a placebo effect.
Media
Early studies have supported the idea that playing video games is a form of neurofeedback, which helps those with self-regulating ADHD and improves learning. On the other hand, ADHD may have great difficulty in getting rid of the game, which in turn can negate any benefit gained from this activity, and time management skills can have a negative impact as well.
Nature
Children who spend time outdoors in nature, such as parks, seem to exhibit fewer ADHD symptoms, dubbed "Green Therapy".
Dietary supplements
Dietary supplements and special diets are sometimes used by people with ADHD in order to reduce some or all of the symptoms. But an article in 2009 at Harvard Mental Health Letter states, "Although vitamin or mineral [micronutrient] supplements can help children who are diagnosed with certain deficiencies, there is no evidence that they are helpful for all children with ADHD Furthermore, vitamin megadoses, which can be toxic, should be avoided. "In the United States, no dietary supplement is approved for ADHD treatment by the FDA.
Some popular supplements used to manage ADHD symptoms:
- Caffeine - ADHD is associated with increased caffeine consumption, and caffeine stimulant effects on cognition may have some benefits for ADHD. Limited evidence suggests a small therapeutic effect that is significantly lower than standard treatments such as methylphenidate and dextroamphetamine while still producing the same or greater side effects.
- Nicotine - The relationship between ADHD and nicotine intake is well known, and limited evidence suggests that nicotine may help correct some of the symptoms of ADHD, although the effect is generally small.
- Omega-3 fatty acids - The Cochrane 2012 review found little evidence that supplementation with omega-3 or other polyunsaturated fatty acids provides improvement in ADHD symptoms in children or adolescents. The 2011 meta-analysis found "small but significant benefits", with benefits "modest compared to the current efficacy of pharmacological treatments available for ADHD". This study concludes that supplementation may be considered worthy of augmentative treatment in combination with the drug because of its "relatively innocuous side effect profile", but not as a primary treatment. Most research on Omega-3 fatty acids is considered to be of very poor quality with widespread methodological weakness.
- Zinc - Although the role of zinc in ADHD has not been explained, there is a small amount of limited evidence that lower tissue zinc levels may be associated with ADHD. In the absence of shown zinc deficiency (which is rare outside developing countries), zinc supplementation is not recommended as a treatment option for ADHD.
- In the 1980s, vitamin B 6 was promoted as a beneficial drug for children with learning disabilities including inattention; However, studies of large doses of vitamins with ADHD children show that they are not effective in changing behavior.
Diet
Perhaps the best known of dietary alternatives is the Feingold diet that involves removing salicylates, artificial colors and flavors, and certain synthetic preservatives from children's foods. However, studies have shown little if any effect of the Feingold diet on the behavior of children with ADHD.
The results of studies on the effect of eliminating artificial food coloring from the diet of children with ADHD have varied considerably. It has been found that it may be effective in some children but because published research has low quality results it can be more related to research problems such as publication bias. The UK Food Standards Agency (FSA) has called for a ban on the use of six artificial food colorings and the EU has decided that some food colorings should be labeled with relevant E numbers as well as these warnings: "may have adverse effects on activity and attention to children. " However, the existing evidence does not deny or support the relationship between ADHD and food coloring.
comorbid disorder
Because of the varied ADHD comorbidities and high rates of comorbidity, special care should be dedicated to certain comorbidities. The FDA was not set up to address this problem, and did not approve of drugs for comorbidities, but such topics have been widely investigated.
Tic disorder
Patients with Tourette syndrome who are referred to a special clinic have high rates of ADHD comorbidity. Patients with ADHD along with tics or tic disorders may also have problems with disruptive behavior, overall function, and cognitive function, noted by comorbid ADHD.
Treatment of ADHD in the presence of tic disorder has long been a controversial topic. Past medical practice states that stimulants (such as Ritalin) can not be used in the presence of tics, due to concerns that their use may worsen tics; However, several pathways have shown that stimulants can be used cautiously in the presence of tic disorders. Some studies suggest that stimulants do not exacerbate tics more than placebo, and suggest that stimulants can even reduce severity. Cochrane Collaboration 2011 reviews concluded that most major ADHD drugs are effective in children with tics, and that stimulants generally do not worsen tics beyond individual cases. Methylphenidate, guanfacine, clonidine, and desipramine are associated with improved tic symptoms. There is still controversy, and PDR continues to carry a warning that stimulants should not be used in the presence of tic disorder, so doctors may be reluctant to use it. Others feel comfortable using it and even advocating for stimulant trials when ADHD coincides with tics, as ADHD symptoms can be more destructive than tics.
Stimulants are first-line treatment for ADHD, with proven efficacy, but they fail in up to 20% of cases, even in patients without tic disturbance. Current prescribed stimulant drugs include: methylphenidate (brand name Ritalin, Metadate, Concerta), dextroamphetamine (Dexedrine), and mixed amphetamine salt (Adderall). Other drugs can be used when stimulants are not an option. These include alpha-2 agonists (clonidine and guanfacine), tricyclic antidepressants (desipramine and nortriptyline), and new antidepressants (bupropion and venlafaxine). There are case reports of deteriorating tics with bupropion (Wellbutrin brand name). There is good empirical evidence for short-term safety and efficacy for the use of desipramine, bupropion and atomoxetine (Strattera).
References
External links
- Media related to Management of attention deficit hyperactivity disorder in Wikimedia Commons
Source of the article : Wikipedia
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