Attention-deficit/hyperactivity disorder (ADHD)
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder, and one of the most encountered behavioral health conditions in children. ADHD is characterized by developmentally inappropriate levels of inattention, impulsivity and hyperactivity. According to national data, ADHD affects about 9.4% of U.S. children ages 2-17; including 2.4% of children ages 2-5 and 4-12% of school-aged children. Boys are more than twice as likely as girls to be diagnosed with ADHD. While initial diagnosis is generally made before age 12, ADHD symptoms may continue into adolescence and adulthood.
Early identification and treatment by a healthcare professional are vital, as untreated ADHD may have serious and long-term consequences, including school failure, delinquency, family stress and disruption, depression, conduct disorder, problems with relationships, substance abuse, accidental injuries and job failure.
When should we consider evaluation?
Increased activity, difficulty with focus and acting impulsively are often variations of normal behaviors. However, when these impair day to day functioning of youth and interfere with their ability to perform regular tasks or pose risk to their safety, further assessment is needed.
Jack is a 7-year-old male with unremarkable medical and psychiatric history who presents with disruptive behavior at school. He is frequently wandering around the classroom, interrupting other children while they are working, and is unable to sit still. Over the past year Jack has been missing more and more assignments and teachers report that though Jack appears to understand the material, he simply cannot complete it.
albuterol inhaler, as needed for asthma
Jack lives with his mother, father, and 3 year old sister. There is no history. of trauma or CPS involvement.
MYTH: Medication will “cure” ADHD.
Fact: While pharmacotherapy can be an important part of the treatment regimen for ADHD, non-medication interventions are also available. Furthermore, ADHD is a chronic condition, so while treatment is effective in reducing symptomology, it is important to be considerate of the time it may take for changes to be seen.
MYTH: ADHD is the result of poor parenting.
Fact: While social factors are important to any child’s wellbeing, research shows that ADHD has a strong genetic and biological basis.
MYTH: Children with ADHD will outgrow the disorder on their own.
Fact: Left untreated, ADHD symptoms can persist into teens years and even adulthood. In fact, 70% of untreated children with ADHD show symptoms throughout their teens, and 50% of untreated children with ADHD present symptoms in adulthood.
ADHD is a clinical diagnosis often made by collecting information from multiple sources including youth, caregivers, teachers, and for older youth, workplace supervisors. A history and physical assessment are obtained to rule out medical conditions and/or to better understand psychosocial factors that may be impacting symptoms. A screening for ADHD symptoms may be completed using a combination of a clinical interview and standardized rating scales. The intent is to determine if those symptoms are contributing to an individual’s social, emotional, behavioral, academic, or work challenges.
While there are several rating scales validated for screening and assessment of ADHD, such as Conner’s scale, Child Behavior Checklist (CBCL), and SNAP-IV; the Vanderbilt Assessment Scales are one of the most used tools to diagnose and monitor ADHD in children and adolescents. For initial diagnosis, the Vanderbilt Assessment Scales are obtained from parents and teachers. The assessment scales specifically ask about the child’s behavior within the past six months. Each section of the Vanderbilt Assessment Scales reflects the symptoms of ADHD, oppositional-defiant disorder, conduct disorder, mood concerns, academic performance, and classroom behavioral performance. Providers are encouraged to use the assessment for initial diagnosis, follow-up to monitor response to medication, and should utilize other objective data to optimize medication use.
Vanderbilt scales were distributed to Jack’s parents and teachers. Jack’s parents report he is forgetful and has been losing things, such as toys and items of clothing. They also note that he has difficulty listening to and following instructions. Teachers note similar symptoms at school and feel this is negatively impacting his learning.
The key feature of attention-deficit/hyperactivity disorder (ADHD) is persistent inattention and/or hyperactivity-impulsivity that interferes with typical functioning or normal development. Symptoms of ADHD are typically present before the age of 12 and persist for a period of at least six months and occur in two or more settings.
Inattention refers to difficulty concentrating, lack of persistence with tasks, disorganization, and wandering off tasks. Hyperactivity refers to excessive motor activity, fidgeting, tapping, or extreme talkativeness. Impulsivity refers to decisions made in haste, often valuing immediate rewards over delayed gratification.
It is also important to consider other medical or mental health conditions before diagnosis of ADHD is established. See “Differential Diagnosis” for details.
After an exam and review of family, health, and school history, it was determined that Jack’s symptoms were consistent with ADHD. No underlying medical or developmental factors were found that could be causing these symptoms. A diagnosis of ADHD, predominantly hyperactive presentation, was made.
Since many symptoms of ADHD resemble those of other behavioral health disorders, it is important to assess these to ensure an accurate diagnosis. However, these disorders may co-occur with ADHD and need careful diagnosis for successful treatment outcomes. Some of the common differential diagnoses and distinguishing symptoms that present similarly to ADHD are listed below:
- Anxiety – Worry and rumination driving poor attention
- Autism – social disengagement and social isolation due to deficits in social communication, temper tantrums due to inability to tolerate a change from expected events
- Bipolar Disorder – Episodic increased activity, poor concentration, elevated mood, grandiosity, increased activity for several days
- Conduct Disorder – Elevated levels of impulsivity, is pattern of antisocial behavior
- Depression – Inability to concentrate, present during major depressive episodes
- Disruptive Mood Disorder – Pervasive irritability and intolerance of frustration; impulsiveness and disorganized thought is not present
- Learning disorder – in the academic setting or during academic activities only
- Medication Induced – Bronchodilators, Isoniazid, neuroleptics, thyroid replacement medication
- Oppositional Defiant disorder – negativity, hostility, defiance, refusal to submit to others’ demands
- Personality Disorders – maladaptive features, self-injury, antisocial behavior, fear of abandonment, lack of empathy
- Substance Use Disorder – nicotine, alcohol, cannabis, opioids- onset of ADHD symptoms follow the onset of frequent use or abuse.
Management strategies for ADHD include non-medication interventions and medication interventions.
Healthcare providers can select effective treatment strategies to promote resilience by assessing patient and family strengths and promoting patient and family engagement in treatment planning.
Shared decision-making can encourage children, teens, and caregivers to have a voice in their care. The Ohio Minds Matter Shared Decision-Making Toolkit is a guide for youth and families to take an active role in their treatment, prepare for their appointment, consider treatment options, document their symptoms, and describe their goals.
Beyond medication, management of ADHD includes psychosocial interventions, which can be implemented both at home and at school.
The goal of behavioral therapy is to encourage positive behaviors and discourage negative behaviors. For younger children, this form of therapy typically includes teaching caregivers and teachers how to provide support and structure. For older children it involves recognizing negative behaviors and managing responses.
Clinical Pearl: Academic Performance
Behavioral therapy for ADHD can have significant impact on reducing impairment in specific domains of functioning, such as academic performance is due to deficits in executive functioning
Standardized parent training programs can be helpful in reducing disruptive behaviors.
Some examples include:
- Parent Child Interaction Therapy (PCIT)
- Triple P Positive Parenting Program
- The Incredible Years
- Helping the Noncompliant Child
- Parent Management Training (for older children)
These programs have been proven effective for improving the parent-child relationship, reducing problem behaviors, and increasing desired behavioral outcomes. Training focuses on enhancing parent responsiveness to developmentally appropriate signals and providing parents with skills to promote compliance with instruction. More specific tips, which may be included within some BPT training programs, include:
- create a routine
- manage distractions
- offer few choices at one time to reduce overstimulation
- clear and specific communication
- help your child plan
- use goals and rewards to track positive behaviors
- discipline effectively
- provide an overall healthy lifestyle for your child
Teachers can also use behavioral therapy strategies in the classroom. The behavioral classroom management approach encourages a student’s positive behaviors in the classroom, through a reward system or a daily report card, and discourages their negative behaviors. The National Resource Center on ADHD provides information for teachers from experts on how to help students with ADHD.
Children less than 6 years of age
Behavior therapy such as parent management training may be recommended as an initial treatment for children under 6 years of age if the ADHD symptoms are mild with minimal impairment or if the diagnosis of ADHD is uncertain.
For children aged 6 or older
Both therapy and medication interventions are recommended for older children. These include maintaining a daily schedule, minimizing distractions, and using charts and checklists to keep the child on track. Positive behavior should be rewarded, and parents should be careful that they are not unintentionally reinforcing negative behaviors. It is also helpful to set small, achievable goals for the child and to find activities in which they can be successful. The child should also be evaluated for an IEP or 504 plan, which can offer additional support with these interventions in the school setting.
For children with comorbid behavioral health conditions
Individual psychotherapy can be helpful for comorbidities such as anxiety and depression but has not been proven to be helpful in ADHD.
Diet and ADHD Symptoms
Both scientists and caregivers have long been interested in the relationship between diet and ADHD symptoms. Many studies have been conducted to try to understand if a significant relationship exists and, if so, what it may mean for preventing or controlling ADHD symptoms. For instance, in the 1970s, it was proposed that artificial colors and flavors caused hyperactivity in children. These preliminary findings have not held up to experimental replication and at the current time there is not a clear relationship between diet and ADHD symptoms in most children.
Some patients, families, and providers may see diets which eliminate certain ingredients and additives as unlikely to harm, and therefore worthwhile even if the chance of benefit is small. Providers can be helpful to caregivers by helping emphasize the evidence base of using well-established treatment for ADHD, both nonpharmacological and pharmacological, and the importance of interventions such as school accommodations, as mainstays of caring for individuals with ADHD. If a family has limited time, energy, and money to devote to helping a child with ADHD, the primary care provider can help emphasize those interventions that are most likely to be beneficial.
The two main classes of medications used for treatment of ADHD include stimulants and non-stimulants.
See the Ohio Department of Medicaid Unified Preferred Drugs List for information about prescription coverage for children enrolled in Medicaid.
Stimulant Prescribing Principles
Before considering a stimulant medication, obtain cardiac history, including sudden cardiac death in first degree relative under age 50, history of congenital heart defect, or conduction defect.
Prescribers may start with a first line stimulant medication from the methylphenidate or dextroamphetamine-amphetamine class, depending on age and ability to swallow solid dosage forms. Long-acting stimulant medications are generally preferred for school-age children.
Although the weight and size of patients can give clues about what doses of stimulant medications will be appropriate to treat ADHD symptoms, there is enough variation in effective doses that a general principle of starting with dosages at or near the bottom end of the dose range is a good practice.
Maximize the dosing of one agent before moving to the next. If ineffective or side effects develop, switch classes within first line options, then move to second- or third-line medication, if needed. Maximize dosing of long-acting stimulant before adding an immediate release formulation medication. It is important to recognize that increasing the dose of the long-acting stimulant does not increase duration of action, but rather tempers symptomatology.
Fortunately, both the beneficial and adverse effects of stimulant medications are usually seen within a few days of starting the medication allowing for relatively rapid determination of stimulant dose effectiveness and tolerability. This means that with a few reliable data points combining patient self-report, observation from caregivers, and information from collateral sources (such as teachers), decisions about increasing, decreasing, or maintaining a medication dosage can be made. Often, increments of 1-2 weeks are a good interval to allow for observations to be collected.
Clinical Pearl: Sharing information with School Staff
Although some caregivers think it may be best not to share medication changes with school staff, thinking this may bias their observations, in many cases informing school staff and proactively soliciting their observations yields better information for refining the treatment plan.
Common adverse effects of stimulant medication are lowered appetite, sleep disruption, feeling nervous or jittery, adverse changes in mood or behavior (either when the medicine is active or when it wears off), headaches, stomachaches, and mild increases in heart rate or blood pressure. Adverse effects are usually, but not always, dose-related, with dose reduction often leading to resolution. Because stimulant medications have a specific duration of activity, one of the most helpful pieces of information to gather about adverse effects is their timing and severity throughout the day (e.g., about an hour after taking a stimulant dose, suggesting a direct adverse effect of the medication, or about 8 hours after taking a long-acting stimulant, suggesting an adverse effect related to when the medicine wears off). This will help guide medication adjustments to address adverse effects.
Reduced appetite from stimulant medications can sometimes be managed by thoughtfully prioritizing adequate nutrition in the morning before the medicine is taken or kicks in, and in the evening when the medicine is wearing off or has worn off. While the appetite may be low at lunchtime, when the stimulant is active, the nutritional intake at other times may compensate, making it adequate over the course of the day.
Clinical Pearl: Side effects and tolerability
Patients receiving stimulant pharmacotherapy may experience increased irritability in two distinct patterns: increased irritability soon after the medication kicks in, indicating poor tolerability of that agent/dose, or increased irritability much later after the medication begins to wear off, indicating a difficulty due to a sharp drop-off of the medication, which in some cases can be addressed with a short-acting stimulant “booster” dose later in the day
Adding extended release guanfacine to stimulant treatment which has been partially effective but limited by side effects can improve symptom control without the adverse effects of increasing the stimulant dose
Clinical Pearl: Medication-naive patients
For medication-naïve patients, it is often useful to trial methylphenidate/dexmethylphenidate first due to somewhat decreased incidence of adverse effects compared with amphetamine.
For additional Psychotropic Medication Prescribing Principles see Prescribing Principles of Psychotropic Medication
Jack was evaluated at school for an IEP to help with organization, test-taking and limiting distractions. Parents implemented a daily schedule for Jack at home with a token economy system in order to reward Jack for positive behaviors. He was also prescribed a low dose of stimulant medication. In the next few months, teachers and parents noticed a great reduction in disruptive behaviors. Jack’s grade improved and by the end of the year, he was excelling academically.
|Generic Medication||Brand Names||Dosage Forms||Starting Dose||Max Dose||Notes|
|5mg BID||60mg divided BID or TID|
|Methylphenidate extended release capsule||Ritalin LA
|10,20,30,40 10,20,30,40,50,60||20mg daily||60mg daily||Can be opened/sprinkled|
|Methylphenidate extended release tablet||Concerta||18,27,36,54||18mg daily||54mg (for 6-12 years)
72mg (for age 13+)
|Cannot be divided or crushed|
|Methylphenidate multilayer extended release capsule||Aptensio XR||10,15,20,30,40,50,60||10mg daily||Can be opened/sprinkled|
|Methylphenidate multilayer extended release capsule||Adhansia XR||25,35,45,55,70,85||25mg daily||70mg daily (85mg daily for adults)||20% IR layer/80% XR layer
Can be opened/sprinkled
|Methylphenidate extended release liquid||Quillivant XR||25mg/5ml solution
Bottles (ml): 60,120,150,180
|20mg daily||60mg daily||Bottles intended to last one month
20% imm. release, 80% ext. release
|Methylphenidate extended release chewable tablet||QuilliChew ER||20,30 scored chew tabs
40 unscored chew tabs
|20mg daily||60mg daily||30% imm. release, 70% ext. release|
|Methylphenidate extended release orally disintegrating||Cotempla XR-ODT||8.6,17.3,25.9||17.3mg daily||51.8mg daily||Orally disintegrating tab|
|Methylphenidate extended release transdermal||Daytrana||10,15,20,30||10mg daily||30mg daily||Possible adverse skin reaction/irritation due to patch
Not suitable for swimming/heavy sweating
|Methylphenidate extended release administered at night||Jornay PM||20,40,60,80,100||20mg daily||100mg daily||Has extended release coating, administered in the evening
Start at 8pm, adjust to between 6:30-9:30 as needed, works in AM
Insomnia at higher rates (33%) than some other stimulants
|Methylphenidate sustained release tablet||Metadate ER||10, 20||20mg daily||60mg daily||Must be swallowed whole|
|Serdexmethylphenidate and dexmethylphenidate||Azstarys||26.1/5.2,39.2/7.8,52.3/10.4||39.2/7.8mg||52.3/10.4mg||Combination of 30% immediate release dexmethylphenidate plus 70% of serdexmethylphenidate, a dexmethylphenidate prodrug; can be opened & sprinkled|
|Generic Medication||Brand Names||Dosage Forms||Starting Dose||Max Dose||Notes|
|Dexmethylphenidate immediate release tab||Focalin||2.5,5,10||2.5mg BID||20mg divided BID|
|Dexmethylphenidate extended-release capsule||Focalin XR||5,10,15,20,25,30,35,40||5mg daily||30mg daily||Can be opened/sprinkled|
|Generic Medication||Brand Names||Dosage Forms||Starting Dose 3-5 years||Starting Dose Age 6+||Max Dose||Notes|
|Adderall (mixed amphetamine salts)
Zenzedi (d-amphetamine sulfate)
Evekeo (d- & l- amphetamine sulfate)
Procentra (d-amphetamine liquid)
|5mg daily or BID
5mg daily or BID
5mg daily or BID
5mg daily or BID
5mg daily or BID
|40mg divided BID|
|Mixed amphetamine salts extended-release capsule||Adderall XR
25mg daily (50mg daily for adults)
|Can be opened/sprinkled
Mydayis has a third phase of extended release, prolonging the duration of action
*Mydayis is FDA approved for ages 12+
|Lisdexamfetamine (prodrug)||Vyvanse||10,20,30,40,50,60,70 cap
10,20,30,40,50,60 chewable tab
|30mg||70mg daily||Capsules can be opened and mixed with water, yogurt, or orange juice|
|Amphetamine extended release orally disintegrating||Adzenys XR-ODT||3.1,6.3,9.4,12.5,15.7,18.8||6.3mg daily||18.8mg daily||Orally disintegrating tab; Package insert suggests conversion between Adzenys and Adderall as 3.1mg Adzenys = 5mg Adderall XR|
|Amphetamine extended-release liquid||Dynavel XR
|Dextroamphetamine extended-release capsule||Dexedrine Spansule||5,10,15||5mg daily or BID||60mg daily||Can be opened/sprinkled|
Tips for Combining Medication
|Partial response to stimulant or have breakthrough symptoms||Consider combining a stimulant with a non-stimulant medication|
|Child continues to experience hyperactivity/impulsivity symptoms||Add clonidine or guanfacine to a stimulant as adjunct|
|Inattention symptoms if intolerability to stimulants with inattention symptoms as primary concern||Add atomoxetine
Note: Avoid combining atomoxetine with stimulants
|Depression comorbidity||Add bupropion to a stimulant as treatment for depression & potential adjunct for ADHD|
|Aggression and mood lability||If adequate response for ADHD, but still significant aggression then may consider addition of a low dose, short term atypical antipsychotic|
Common Side Effects for Stimulant Medications
Reduced appetite/weight loss, insomnia, nervousness, stomachaches, headaches, mild irritability as medicine kicks in, mild irritability as medicine wears off, mild social withdrawal, mild increases in heart rate or blood pressure
Serious Side Effects for Stimulant Medications (Rare)
Severe mood problems, serious aggression, hallucinations, severe social withdrawal, severe tics, large increases in heart rate or blood pressure
Tips for Follow-Up Medication Management
When a stimulant medication is well-tolerated but ineffective, the dose can be increased. Improvements are often seen right away, so with good data from caregivers and schools about symptoms/response to the current dose, this titration could occur after a brief time (e.g., one week).
Obtaining information about the timing of when the medicine wears off and when side effects are seen is an important part of medication follow-up. For instance, patients receiving stimulant pharmacotherapy may experience increased irritability in two distinct patterns: increased irritability soon after the medication kicks in, indicating poor tolerability of that agent/dose, or increased irritability much later after the medication begins to wear off, indicating a difficulty due to a sharp drop-off of the medication, which in some cases can be addressed with a short-acting stimulant “booster” dose later in the day.
Patients who tolerate methylphenidate without significant side effects but do not seem to experience benefit may be trialed on an amphetamine stimulant such as mixed amphetamine salts or lisdexamfetamine, which sometimes shows efficacy in those who do not respond to methylphenidate, although the likelihood of stimulant-related side effects with amphetamine is modestly higher.
Nonstimulant Medication Prescribing Principles
Although non-stimulant medications for ADHD have a lower effect size, they can be a good choice for individuals who do not tolerate stimulant medications.
Nonstimulant ADHD medications, as a group, improve ADHD symptoms in fewer patients and to a smaller degree than stimulant medications. However, they may be a good choice for some patients, either alone or in combination with stimulant medications. The prototypical patient for whom nonstimulant ADHD medications are helpful is one who has not been able to tolerate adverse effects of stimulant medication. Nonstimulant medications are used as an alternative for patients whose caregivers are averse to stimulant medication. Sometimes those caregivers can be reassured that stimulant medications are some of the best- and longest-studied medications for youth, and that we have a large amount of clinical experience to demonstrate that they are generally safe and effective.
FDA-approved nonstimulant ADHD medications can be divided into two basic groups: alpha agonist medications (guanfacine and clonidine) and norepinephrine reuptake inhibitors (atomoxetine and viloxazine). Among the alpha agonists, guanfacine has more specificity for the brain targets of ADHD therapy, so it generally has fewer adverse effects compared with clonidine. However, both can cause sedation, lightheadedness (especially when standing up), orthostatic hypotension, and headache). For norepinephrine reuptake inhibitors, common adverse effects are gastrointestinal side effects, reduced appetite (although usually milder than seen with stimulant medications), and mild changes in mood and irritability.
Clinical Pearl: ADHD Nonstimulant Medication Overview
Both clonidine extended release and guanfacine extended release can cause sedation and orthostatic hypotension, but this side effect is less common in guanfacine because its activity at receptors is more selective
Patients receiving atomoxetine may take a long time to achieve the full effect of the medicine (a mean time to optimal response of 14 weeks)
|Generic Medication||Brand Names||Dosage Forms||Starting Dose||Max Dose||Notes|
|Intuniv||1,2,3,4||1mg daily||4mg daily in children 6-12; 7mg in children 13+||α-agonist (α2A-specific)
Can be given morning or evening; can be used together with stimulant
(extended release tablet)
|Kapvay||0.1||0.1mg daily to BID||0.2mg BID||α-agonist (less specific for α2A)
BID dosing if higher than 0.1mg per day
|Atomoxetine||Strattera||10,18,25,40,60,80,100||10mg daily||100mg daily||Capsule cannot be opened|
|Qelbree||100,150,200||25mg daily||70mg daily (85mg daily for adults)||Capsule can be opened and sprinkled|
Guanfacine and clonidine are alpha agonists; atomoxetine and viloxazine are norepinephrine reuptake inhibitors.
Common Side Effects for Alpha Agonists (guanfacine and clonidine)
Lightheadedness/dizziness, especially when sitting up or standing up; mild sedation; headache.
Serious Side Effects for Alpha Agonists (Rare)
Syncope (fainting); large decreases in heart rate or blood pressure.
Common Side Effects for Norepinephrine Reuptake Inhibitors (atomoxetine and viloxazine)
Gastrointestinal side effects: upset stomach, diarrhea, nausea, vomiting, reduced appetite, mild increases in irritability.
Common Side Effects for Norepinephrine Reuptake Inhibitors (Rare)
Large increases in irritability, suicidal ideation, liver problems.
While medications and psychosocial treatments can be effective for symptom management, ongoing dialogue about symptoms and side effects is important. Healthcare providers should schedule frequent follow up visits to determine whether treatment goals are being met.
- Assess symptom changes in multiple domains (home and school)
- Monitor for medication side effects
- Monitor appetite, height, and weight
- Monitor sleep hygiene
- Reinforce use of resources for families and youth
- Refer to support groups, peer groups, education sources
- To promote shared decision making, a decision-making tool kit and video have been developed. The use of the toolkit can empower children, teens, and caregivers to have a voice in their care. The toolkit includes pages for “how to prepare for your visit,” “treatment options and plans,” “tools to help rate your symptoms”, and blank areas for notes.
Resources for families
Resources for youth
Frequently Asked Questions (FAQs)
Are youth with ADHD more likely to have co-occurring conditions than typical peers?
Yes. A large majority of individuals with ADHD have a co-occurring condition, frequently related to mood, behavior, sleep, or substance use. Youth with ADHD are also more likely to be overweight or obese.
Will putting someone with ADHD on a restricted diet reduce symptoms of ADHD?
While a healthy diet can be beneficial to any child, there has been no evidence that restricting certain foods or nutrients will significantly reduce ADHD symptoms. Evidence-based medication and behavioral therapies are recommended treatments for managing ADHD.
My child is able to sit still and watch tv or play a game for an extended time at home. Could they still have ADHD?
Parents may question that their child has ADHD due to their ability to sustain focus on certain tasks, but these are often favored tasks that hold particular interest. Since ADHD is due to a limitation in executive functioning skills, children may be able to complete some tasks while still experiencing deficits in emotional regulation, planning and organizing skills that should be addressed.
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Cigna. (2021). ADHD myths and facts. https://www.cigna.com/individuals-families/health -wellness/hw/adhd-myths-and-facts-hw164660
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Zuckerbrot, R. A., Cheung, A., Jensen, P. S., Stein, R., Laraque, D., & GLAD-PC STEERING GROUP. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics, 141(3), e20174081. https://doi.org/10.1542/peds.2017-4081