Adult ADHD (Attention Deficit Hyperactivity Disorder in Adults)

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What Is Adult ADHD?

Attention deficit hyperactivity disorder (ADHD) is well recognized in children and adolescents, and is increasingly being recognized in adults. The labels used to describe this cluster of problems have changed many times over the past 100 years, but currently attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) are the most commonly used diagnostic terms. As with most psychiatric disorders, the causes of ADHD are not fully understood, but the condition is thought to be due to a combination of genetic factors, prenatal exposures, and life experiences. Symptoms of ADHD lead to poorer performance, particularly at school and work, than would be expected.

Attention deficit hyperactivity disorder is defined as a neurodevelopmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). ADHD includes primarily problems with inattention and/or hyperactivity. However, because inattention and hyperactive behavior affect emotions and relationships with others, the impact of ADHD can be broad and pervasive. The problems with attention and/or hyperactivity start in childhood, but for many people, these continue into adulthood too. In order to be diagnosed with ADHD, an adult must have a history of symptoms that start during childhood. The DSM-5 requires the presence of symptoms before the age of 12, since recall of symptoms earlier in life is difficult or impossible to reliably establish. Therefore, by definition, there can't be a diagnosis of adult-onset ADHD.

A recent study suggested that there may actually be a different type of ADHD that starts in adulthood. However, this finding is quite controversial and contrary to currently accepted diagnosis and treatment recommendations. A second study was published shortly after this one and argued that diagnoses of adult-onset ADHD are actually better explained by substance use disorders, sleep disorders, and other conditions that can impair attention.

It is important to recognize that inattention due to ADHD does not affect all areas in someone's life equally. When people with ADHD are involved in an area that naturally holds their interest, they may pay attention as well as, or nearly as well as, others. However, when tasks are repetitive or hold less interest for that person, these individuals often experience greater difficulty maintaining focus and remaining on task. Because of this, those with ADHD may be prone to procrastination, and their behavior may be perceived as immature or inappropriate.

As children with ADHD grow up, their overtly hyperactive-impulsive qualities often diminish, while the inattentive and disorganized patterns of behavior tend to persist. Adults with ADHD often fit this pattern: inattention, disorganization, and low tolerance of frustration or boredom, combined with the childhood history of inattention and hyperactivity. In adults, inattention tends to cause the most impairment and problems.

Compared with unaffected people, those with ADHD often require more practice over longer periods of time to develop effective habits and behavior. These issues can result in complications in many aspects of life, including school or job achievement, performance in athletic activities, driving, as well as success in relationships, specifically friendships, dating, and marriage.

The acceptance of adult ADHD has changed dramatically over the last 20 years. Based on accepted knowledge at the time, the DSM-IV indicated that most adolescents and adults outgrew ADHD and did not have persistent symptoms as adults. More recently, however, it is thought that 60%-70% of adults who had ADHD as children continue to have significant symptoms that cause impairment. Recent studies indicate that around 5% of children and 2%-4% of adults are affected by ADHD. Males seem to be more likely to have ADHD, with one and a half to two times as many males as females affected. When assessing adults for ADHD, it is critical to establish the presence of symptoms in childhood, and to rule out other psychiatric and non-psychiatric medical disorders that can cause attention problems (this includes mood, anxiety, and psychotic disorders; personality disorders; substance use disorders; sleep disorders; and cognitive disorders). Adults with ADHD are also at higher risk of also having other comorbid psychiatric disorders, including substance use disorders, depression, and anxiety disorders.

What Are Causes of Adult ADHD?

Rather than having any single cause, attention deficit hyperactivity disorder (ADHD) is thought to be related to both genetic and life-experience factors. ADHD tends to run in families, supporting a genetic component. However, no specific gene(s) have been shown to cause ADHD. Additionally, many people with ADHD may not have a personal family history. Similarly, exposure to various toxins or experiences can increase the risk of having ADHD. Prenatal exposure to tobacco, alcohol, and other drugs of abuse can increase the risk of ADHD. Similarly, low birth weight, traumatic birth, or other early childhood traumas or infections may also increase an individual's risk. However, it is critical to understand that most people with any one of these exposures still will not have ADHD.

Biologically, ADHD is a neurochemical and neuroanatomical disorder, meaning that specific brain chemicals and brain regions are affected. People with ADHD are thought to have several chemicals (still to be determined) in the brain that are not present in the right quantities in the right places at the right times. Both dopamine (DA) and norepinephrine (NE; noradrenaline) are brain chemicals involved in regulating both attention and reward pathways in the brain and are thought to be affected by ADHD. Many of the medications used to effectively treat ADHD alter brain levels of DA and NE, adding support to the hypothesis that ADHD is related to their function.

Neuroimaging research has shown both that children with ADHD show differences in how their brains develop, as well as identifying areas in the adult brain that seem to function differently. Although brain images are helping us to understand these disorders, an MRI or CT scan cannot be used to establish a diagnosis of ADHD.

Risk factors for childhood ADHD are thought to include male gender, but some of that is known to be the result of the symptoms of ADHD potentially seeming less apparent in girls. Since ADHD in adults is equally identified in men and women, gender is not a risk factor for this disorder in adults. Other risk factors for ADHD are thought to include medical or mental health issues in a father, trauma before birth, being the product of unintended pregnancy, and history of head trauma. Being breastfed is thought to be a protective factor against developing ADHD.

ADHD Testing

Testing for ADHD involves a number of screening tools, full history and physical, self-tests, observations, and other neurocognitive evaluations. There is no currently accepted blood test or radiologic test for the disorder, though it is probable that there will be in the not too distant future.

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ADHD in Adults

What Are Adult ADHD Symptoms and Signs?

Symptoms of attention deficit hyperactivity disorder (ADHD) in children and adolescents are predominantly external and easy to observe, such as physical hyperactivity. An exception is predominantly inattentive ADHD, formerly referred to as ADD, which is more common in girls. With age, a decrease in observable symptoms of ADHD seems to occur. Adults with ADHD have a longer delay before refocusing when their attention is misdirected, and they have difficulty switching tasks. The hyperactivity and impulsivity of adult ADHD are often more subtle than those symptoms types in children. For example, while hyperactivity may result in children being fidgety and frequently getting up from sitting, this symptom in adults may involve the adult getting bored easily and being unhappy about having to sit still rather than having to frequently change their position. On neuropsychological tests, these individuals often have trouble with sustained effort, planning, organization, visual tracking, and listening attentively.

ADHD is characterized by a long-term history of inattention, impulsiveness, and variable amounts of hyperactivity. Remember that all of these symptoms are normal human characteristics, so ADHD is not diagnosed solely based on the presence of these normal human behaviors. ADHD is determined by the degree of these behaviors and their interference with important areas of life. People with ADHD have these normal human characteristics to an excessive degree, with a poor ability to easily control them.

The Evolution of ADHD Characteristics From Childhood to Adulthood
CharacteristicChildhood ManifestationAdult Manifestation
HyperactivityCannot sit still
Fidgety, restless
Always on the go
Inner restlessness
Inability to relax
Unhappy/discontent when inactive
ImpulsivityBlurting out
Touching or exploring
Can't stay in line
Temper tantrums or outbursts
Interrupting, impatient
Snap decisions, recklessness
Switching tasks rapidly
Feeling "down" when bored or "up" when excited/stimulated
InattentionDistractible
Cannot finish work
Does not appear to hear
Often forgetful
Disorganization, forgetfulness
Poor time management
Misses parts of conversations

Although some adults with ADHD may not meet the full criteria used to diagnose ADHD in children, they may still experience significant impairment in certain aspects of life. Depending on their professional or domestic situation, these adults may need to deal with more complex abstract issues that can be difficult depending on the severity of their ADHD. Consequently, a given individual's perception of his or her own degree of impairment may vary.

Some characteristics of adult ADHD include the following (remember these are normal human behaviors; ADHD is diagnosed based on the presence and severity of more than one of these characteristics):

  • Persistent motor hyperactivity: A person may feel restless, be unable to relax or settle down, or be discontent unless active.
  • Attention difficulties: Someone may have trouble keeping his or her mind on a conversation. For example, a man or woman may be constantly aware of other things going on around him even when trying to filter them out. Or the individual may have difficulty reading, finishing a task, with focus, or may experience frequent forgetfulness.
  • Affective lability: This means that someone shifts from a normal mood to depression or excitement, and these shifts can be either reactive or spontaneous.
  • Disorganization or inability to complete tasks: An affected person may be disorganized at work, home, or school. One frequently does not complete tasks or switches from one task to another.
  • Short temper with short-lived explosive outbursts: A person may lose control for short times or be easily provoked to anger or constantly irritable, and these problems may interfere with personal relationships.
  • Impulsivity: Impulsiveness may be minor (for example, talking before thinking, interrupting conversation, impatience) or major. Abruptly starting or stopping relationships (for example, multiple marriages, separations), antisocial behavior (for example, shoplifting), and excessive involvement in pleasurable activities without recognizing possible consequences (for example, buying sprees) are examples of major impulsivity. The bottom line is that waiting to do something induces discomfort.
  • Emotional overreaction: Someone may react excessively or inappropriately with depression, confusion, uncertainty, anxiety, or anger to ordinary stresses. These emotional responses interfere with problem-solving abilities.

Other psychiatric conditions, such as a substance-abuse disorder, major affective disorder (like major depression or bipolar disorder), anxiety disorders, schizophrenia or schizoaffective disorder, borderline personality disorder, antisocial personality disorder, and schizophrenia must be ruled out as a cause of the symptoms. Similarly, other medical conditions, including sleep disorders (like obstructive sleep apnea [OSA]; insomnia; sleep deprivation), traumatic brain injuries, cognitive disorders, or epilepsy (seizures) may also cause problems with attention.

How Do Health Care Professionals Diagnose Adult ADHD?

In adults, the DSM-5 requires five or more symptoms of inattention, and/or five or more symptoms of hyperactivity to make the diagnosis. In children, six or more symptoms are required; this is a recognition that there may be fewer symptoms (or they may be more subtle) in adults, but still they cause significant impairment. Many of the symptoms must have been present at or before age 12. The symptoms must cause significant impairment in at least two different settings (for example, home and work; school and home; etc.) and must not be better explained by another diagnosis.

Several screening tools, self-tests or checklists, spousal reports, and parent report questionnaires, including the Connors rating scale, the Adult ADHD Self-Report Scale Symptom Checklist, and others are available for the assessment of adults with attention deficit hyperactivity disorder (ADHD). However, the diagnostic power of these tests is still being determined, so adult ADHD is diagnosed from qualitative data more than from quantitative tests. It is generally useful (and recommended) to get a history of symptoms from others close to the individual (for example, parents, spouse or partner, siblings) to better confirm the diagnosis.

Currently, there are no blood tests, genetic tests, or imaging studies that can accurately diagnose ADHD.

What Specialists Treat Adult ADHD?

Most specialists who treat mental health disorders such as depression and anxiety also have experience in treating ADHD, particularly since it is a relatively common disorder. In the past, child and adolescent psychiatrists and pediatricians had the most experience with ADHD treatment, since the majority of diagnoses were in children and adolescents. As awareness of adult ADHD has increased (and as those diagnosed as children have grown to adulthood), more adult psychiatrists and family medicine and internal medicine doctors have gained expertise with treating adults with ADHD. Only licensed physicians (MD or DO doctors, including psychiatrists, pediatricians, family doctors and primary care providers) or Advanced Practice Nurse Prescribers (APNP) working with physicians can also prescribe medications for ADHD. You may find that some professional therapists and counselors (clinical psychologists, clinical social workers, professional counselors) will specialize in therapy approaches to addressing ADHD symptoms. A variety of other professionals may provide education or coaching services to help with ADHD. However, they may not be required to have professional licensing, and it is important to look into their experience, training, and references from clients or referring providers.

When Should Someone Seek Medical Care for Adult ADHD?

Adult attention deficit hyperactivity disorder (ADHD) can have a negative impact on the life of the sufferer. Some commonly reported problems include the following:

  • Friendship, dating, and marital instability
  • Academic, vocational, and extracurricular (for example, in athletic, club, or volunteer activities) success below what is expected based on intelligence and education
  • Alcohol or drug abuse
  • Atypical responses to psychoactive medications
  • Antisocial personality
  • Depression, anxiety, and low self-esteem

Adult ADHD is diagnosed based on determining the presence of symptoms during childhood, establishing a long-term pattern, and demonstrating current impairment. This information can be gathered from interviewing parents, friends, siblings, and spouses or partners, as well as from screening tools, including rating scales and self-reports.

Questions to Ask the Doctor About Adult ADHD

Finding a doctor who treats adult attention deficit hyperactivity disorder (ADHD) could be difficult since the occurrence of this condition in adults is only recently recognized. The following are some helpful questions to ask when looking for medical care:

  • Are you familiar with diagnosing ADHD in adults?
  • How long have you been diagnosing ADHD in adults?
  • How many adults have you given the diagnosis of ADHD in the past five years? (The more the better, but even a few a year is far better than none.) What percent of your practice has a primary diagnosis of ADHD? (Again, the higher the percentage the better, but 5%-10% is far better than none.)
  • How familiar are you with the day-to-day burden of having ADHD? (How intimate is the doctor's understanding of ADHD on a daily basis?)
  • What is your treatment philosophy? (You want to determine if the clinician will work with you and be open to suggestions if he or she will call all the shots or if the treatment is individually tailored.)
  • Do you regularly read materials or attend conferences related to adult ADHD? (Try to learn what the clinician does to maintain current knowledge about adult ADHD and its treatment protocols.)
  • How do you diagnose ADHD? How many visits will it take and how much will it cost?
  • How long will I have to wait for an appointment?
  • What medications are you likely to prescribe? (Ask psychologists how they handle the medication part of treatment because psychologists cannot prescribe medications in most areas.)
  • Keep track of who you called and how they answered these questions.

Are There Adult ADHD Treatments and Home Remedies?

Research suggests that adults with attention deficit hyperactivity disorder (ADHD) often respond extremely well to stimulants and at times antidepressants. Treatment options and successes are similar to those in childhood ADHD. Counseling, also called psychotherapy, can play an important role in treatment by helping to develop increased awareness of ineffective habits. Therapy can also be a way to develop activities to build organizational and planning skills. However, no current research has demonstrated that counseling alone will eliminate the actual symptoms of ADHD; rather, counseling can become more effective once an effective medication is found. Medication will "start the engine" but not necessarily provide a way to "steer." In other words, counseling may help with issues of marital instability or poor interpersonal skills but by itself will not end inattention, impulsivity, or feelings of restlessness. So far, there is not much research showing consistent benefit from home remedies in the treatment of adult ADHD.

What Are Medical Treatments for Adult ADHD?

When medication is used effectively for attention deficit hyperactivity disorder (ADHD), patients notice a significant improvement in control. Objective observers, such as acquaintances or coworkers, should notice more focus, better concentration, and improved task completion.

Remembering what medicines do and do not do is very important. Medicine, when used successfully, simply helps a person with ADHD function more like a person without ADHD. As a comparison, using medication is like putting on glasses. It makes the system function more appropriately, just like glasses help a person achieve 20/20 vision. Medication alone will not make a person with ADHD sit down and write a paper any more than glasses alone will. Medication allows the nervous system to send its chemical messages more efficiently, but it does not provide skills or motivation to perform.

Medication is designed to help a person with ADHD be less distracted, so that he or she can stick to a plan and achieve daily goals. People with ADHD who are on effective medication can have improved attention span, concentration, memory, coordination, mood, and task completion. At the same time, daydreaming, hyperactivity, anger, and immature or oppositional behavior may decrease. Medical treatment allows a person's intellectual capabilities that were already present to function more appropriately.

What Medications Treat Adult ADHD?

The medications available for managing attention deficit hyperactivity disorder (ADHD) can have slightly different effects from individual to individual, and currently no method exists to tell which will work best. Medications indicated for ADHD are thought to work by improving the imbalance of neurochemicals that are thought to contribute to ADHD.

Some commonly prescribed medications include the following:

If one medication does not work effectively, some of the others are often tried because individuals may respond quite differently to each one. Medications in different groups used in combination may be more effective than each medication alone for some people. In general, the medications used to treat ADHD in adults are the same ones used to treat ADHD in children.

Stimulants are the most commonly used class of medications for treating ADHD in adults and children. All of these medications increase brain levels of dopamine and norepinephrine. Both of these brain chemicals are thought to be related to the ability to sustain attention. Stimulants are misused or abused by some people, and can be addictive, so they should be used with care and may not be appropriate for some individuals. Almost all people will see an improvement in their attention, focus, and performance on certain tasks while taking a stimulant. This is important to know, since there is a common myth that a positive effect from a stimulant can prove a diagnosis of ADHD. On a related note, it has become increasingly common for high school and college students to misuse stimulants (for example, take them without a prescription or take more than prescribed) as a cognitive enhancer or performance-enhancing drug (PED) as a way to try to improve their academic performance. While there are far fewer studies on the long-term effects of stimulant medications like Ritalin, Adderall, or Focalin, some research shows that the effectiveness of stimulants sometimes wanes over time.

The FDA approved nonstimulant medications work in a slightly different way. Atomoxetine (Strattera) increases norepinephrine levels and is not an addictive medication. Both guanfacine and clonidine modulate the sympathetic (fight or flight) nervous system and are thought to decrease the impulsiveness related to ADHD.

Certain antidepressants are also used to treat ADHD, since they may also affect dopamine and norepinephrine levels. None of the antidepressants have an FDA approval for ADHD treatment; however, they may be a useful treatment option, particularly when stimulant medications are contraindicated, have caused intolerable side effects, or have not improved symptoms. The antidepressants most commonly used for ADHD are bupropion (Wellbutrin), venlafaxine (Effexor), and duloxetine (Cymbalta). Older tricyclic antidepressants (TCAs) such as imipramine (Tofranil, Tofranil-PM), desipramine (Norpramin), and nortriptyline (Pamelor) are less often prescribed for treatment of ADHD because they are more likely to cause more serious side effects.

Antidepressant medications and atomoxetine may increase the risk of suicidal thinking and behavior (in children, adolescents, and young adults in their early 20s) as side effects of the medication, particularly in individuals with a history of bipolar or other mood disorder, or a personal or family history of suicidal behavior.

Medication can help some or all of the following areas:

  • Academic underachieving and inattentiveness
  • Hyperactivity or fidgeting
  • Verbal and/or behavioral impulsivity (for example, blurting out, interrupting others, acting before thinking)
  • Difficulty falling asleep at night
  • Trouble waking up (not getting out of bed in the morning)
  • Excessive irritability without cause and/or easy frustration
  • Episodic explosiveness, emotional outbursts, or temper tantrums
  • Unexplained and persistent emotional negativity

If an ADHD medication is not significantly helping with a number of these concerns or is causing uncomfortable or problematic side effects, ask about changing the dosage or changing medicine.

While a number of natural remedies and changes in diet to treat ADHD have been tried, research indicates that many such interventions are either too restrictive to daily life to implement in a realistic way or have yet to be found to have a significant impact on ADHD symptoms.

Psychotherapy for Adult ADHD

Although medications are generally considered to be the first-line treatment, psychotherapy may be an option when medications are not effective or are not an option for other reasons. The types of psychotherapy with the best evidence for improving ADHD symptoms are cognitive behavioral therapy (CBT) or behavioral therapy. CBT for ADHD is aimed at improving cognitive organization and planning as well as training of behaviors that are impairing function. CBT can also be combined with medication, and some studies have shown this combination to be more effective than either treatment alone.

Adult ADHD Coaching and Support Groups

Most adults with attention deficit hyperactivity disorder (ADHD) are undiagnosed, untreated, and unaware that help is available. Their symptoms occur in varying types and severity from impairment in interpersonal relations to underemployment to low self-esteem and being insecure.

An ADHD coach is professionally trained to guide and support a person in overcoming the challenges of living with ADHD at work, school, and home. In contrast to CBT, coaching can be used on an as-needed basis and tends to focus on a particular problem.

Specifically, ADHD coaches help people with ADHD to do the following:

  • Create tools to stay on track.
  • Improve organizing skills and design organizing systems.
  • Plan projects, clearly identify tasks, and manage time.
  • Increase self-awareness.
  • Set and reach goals.
  • Improve crucial lifestyle habits such as diet, sleep, and exercise.
  • Improve relationship and communication skills.

ADHD coaching can supplement the treatment from a doctor and counselor. Coaches have frequent contact with their clients (in person or over the phone) and can help determine the success of different medications or other treatments, providing observations and advice that can be used to tailor treatment.

ADHD coaching is not psychotherapy; some people work with a coach while also working with a therapist or counselor. Coaching sessions deal with what's happening in the client's life with emphasis on challenges, opportunities, and strategies for success. Coaches can provide support between sessions by email or phone, and some assign homework that helps the client accomplish his or her objectives in living with ADHD.

In addition to coaching, which is not covered by insurance and can be expensive, many support groups are available for adult ADHD. Groups can be found online or through a therapist.

Is It Possible to Prevent ADHD?

Preventing exposure of people to environmental toxins like cigarette smoke in the womb, mercury, lead and pesticides before or after birth seem to help prevent ADHD. Being breastfed and having adequate intake of nutrients like vitamins, zinc, magnesium, and omega-3 fatty acids are thought to be other protective factors against developing ADHD. Encouraging exercise in young children is believed to have a role in preventing ADHD by promoting neurological development.

What Is the Prognosis of Adult ADHD?

An estimated one-third of children with attention deficit hyperactivity disorder (ADHD) progress satisfactorily into their adult years, while another one-third continue to experience some problems, and the final one-third continue to experience and often develop significant problems.

Many of these negative outcomes are linked to continued, severe, and persistent ADHD symptoms. Studies are demonstrating that adults with ADHD report similar symptoms as described in children with ADHD, but the daily impact of these symptoms is clearly different. Treatment with appropriate medication can significantly improve the outcome for ADHD. For example, effectively managing symptoms with medication can be a key factor in the prevention of another psychiatric disorder or of academic failure.

Other significant statistics about adult outcomes of ADHD include that only 11% of adults with this disorder are accurately diagnosed or receive treatment, nearly 50% of adults with ADHD also suffer from an anxiety disorder, about 40% have a different type of co-occurring mood disorder, and about 15% also develop a substance-abuse disorder.

Emerging evidence suggests that the combination of medication, cognitive therapy, and life coaching appears to significantly improve the prognosis of adults with ADHD.

Where Can People Find More Information on Adult ADHD?

Attention Deficit Disorder Association
PO Box 543
Pottstown, PA 19464
484-945-2101

Attention Deficit Disorder Resources
223 Tacoma Ave S #100
Tacoma, WA 98402
253-759-5085

Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD)
8181 Professional Place, Suite 150
Landover, MD 20785
National Resource Center on AD/HD
800-233-4050

Northern County Psychiatric Associates, Attention Deficit Disorder

National Alliance on Mental Illness (NAMI), "ADHD"

National Institutes of Mental Health, "Attention Deficit Hyperactivity Disorder (ADHD)"

Reviewed on 11/30/2017

REFERENCES:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, fifth edition. Washington, D.C.: American Psychiatric Association, 2013.

Biederman, J., M.C. Monuteaux, T. Spencer, et al. "Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study." Pediatrics 124.1 July 2009: 71-78.

Caye, A., T. Rocha, L. Anselmi, et al. "Attention-Deficit/Hyperactivity Disorder Trajectories From Childhood to Young Adulthood: Evidence From a Birth Cohort Supporting a Late-Onset Syndrome." JAMA Psychiatry 73.7 (2016): 705-712.

Christiansen, H., B. Kis, O. Hirsch, et al. "German validation of the Connors adult ADHD rating scales (CAARS) II: reliability, validity, diagnostic sensitivity and specificity." European Psychiatry 27.5 July 2012: 321-328.

Curtis, L.T., and K. Patel. "Nutritional and environmental approaches to preventing and treating autism and attention deficit hyperactivity disorder (ADHD): a review." Journal of Alternative Complementary Medicine 14.1 Jan.-Feb. 2008: 79-85.

Golmirzaei, J., S. Namazi, S. Amiri, et al. "Evaluation of attention-deficit hyperactivity disorder risk factors." International Journal of Pediatrics 2013.

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Wang, G-J., N.D. Volkow, T. Wigal, et al. Long-term stimulant treatment affects brain dopamine transporter level in patients with attention deficit hyperactive disorder. PLoS ONE 8.5 (2013): e63023.

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