Download Report

ADHD
A guide for
UK teachers
www.livingwithadhd.co.uk
ADHD A guide for UK teachers
Contents
Introduction – teachers and ADHD
Background to ADHD
What is ADHD?
Subtypes
How common is ADHD?
What causes ADHD?
The role of the genes
The role of other factors
Brain processes
Other problems
Identification and diagnosis: the teacher’s role
The referral process
The specialist team
Treatment: advice and support
Treatment options
Help with other problems
Medication
Main agents
The development of long-acting medicines
Treatment expectations
Length of treatment
Dietary approaches
Treatment recommendations
Practical tips for teachers
Other useful information
References
Notes
4
6
6
7
7
7
8
8
8
8
10
10
11
12
12
12
14
14
14
15
15
17
18
19
21
22
23
3
Introduction Teachers and ADHD
Knowingly or not, you’ve probably already taught a child with Attention Deficit
Hyperactivity Disorder (ADHD). The condition affects an estimated 5% of children1,4 –
one or more in every class of 30 on average. While there is concern in some countries
(especially the US) that ADHD is over-diagnosed and over-treated, it remains the case
that in the UK some children with ADHD still go unrecognised and untreated.2
ADHD causes significant disruption to children’s lives (and to the lives of those around them) both at home and
at school. It leads to underachievement at school, and can result in anti-social behaviour, delinquency and drug
abuse in later life.3
ADHD is a valid clinical condition, with clear diagnostic criteria, an increasingly well-understood biological basis,
and effective treatments supported by both NICE (The National Institute for Health and Clinical Excellence)4 and
SIGN (The Scottish Intercollegiate Guidelines Network).2
This document is designed to provide summary and guidance in relation to ADHD, specifically tailored to
the needs of teachers. Separate but complementary versions are available for primary care workers and
parents/carers.
All three versions are grounded in the European Guidelines for Hyperkinetic Disorder,1 which have recently been
updated by a group of expert researchers and clinicians working in different countries across Western Europe.
Recognising that practice varies between countries, these European guidelines are not prescriptive but consist
of a series of statements of evidence based or consensus-driven general principles rather than detailed protocols.
On some points of detail (for example certain medications and the significance of food additives) this document
reflects current UK perspectives rather than the European guidelines.
www.livingwithadhd.co.uk
While most specific treatments for ADHD will be given in secondary care, children with ADHD have behaviour
problems that, by definition, affect both the home and the school, and the teacher has a number of important
roles to play:
• A
teacher may be the first person to express concern about a child’s behaviour and suggest seeking medical
help or advice.
• Specialists
investigating possible cases of ADHD often want to find out as much as possible about how the child
behaves and performs at school.
• T
eachers sometimes play an important role in treatment, working with psychologists and other specialists to
develop approaches to the organisation of learning and classroom management that will help children improve
their behaviour.
The aim of this guide is to provide you with the sort of information you will find useful as teachers, as well as
some idea of what will happen once the child moves to specialist care. First, we provide some background to the
condition. This is followed by a discussion of the whole process of diagnosis and treatment, with a special focus
on the role of the teacher. We recognise that training for teachers in this area is limited, and this guide is a small
contribution towards improving the situation.
We hope that the information about ADHD contained in this guide will help teachers to contribute towards
improved management of this common, damaging and often misunderstood condition.
Dr David Coghill
University of Dundee
Professor Edmund Sonuga-Barke
University of Southampton
5
Background
to ADHD
•
•
•
•
ADHD is a clearly defined clinical condition.
ADHD is common.
ADHD tends to run in families, but probably results from a combination of factors.
Children with ADHD often have other problems.
What is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is a
clearly defined clinical condition and not just a label for
naughty or badly brought-up children.
ADHD is diagnosed when a child exhibits abnormally
high levels of:
• Inattention5 (short attention span, easily distracted,
doesn’t finish things, disorganised, forgetful etc)
and/or
• H
yperactivity and impulsiveness5 (fidgets, can’t
sit still, always on the go, talks too much, interrupts,
can’t wait their turn etc).
www.livingwithadhd.co.uk
To qualify as true ADHD, these problems:5
• Must be long-term (present for at least 6 months).
•Must be abnormal for the age and stage of
development of the child (what’s normal in a 2-yearold is not normal in a 10-year-old).
•Must have been present before the age of 7.5
Symptoms are nearly always seen before the age
of 5 years.1 ADHD is a developmental disorder, and
doesn’t appear suddenly.
•Must be genuinely disruptive to the child’s everyday
performance and wellbeing5 – mere naughtiness at
home or not doing well at school is not enough.
•Must occur in more than one place,5 for example
both at home and at school. Problems that are
present just at home or just at school, are likely
to have other causes.
Subtypes
What causes ADHD?
Not all children with ADHD are hyperactive. Some
children only have problems with inattention and
some (actually very few) only have problems with
hyperactivity and impulsiveness, but many have
a combination of both types of problem.5
The exact causative mechanisms of ADHD are not
known, but evidence from several sources points
to the importance of biological factors.
The term “Hyperkinetic Disorder” is also sometimes
used to describe those children with the most severe
ADHD, where the symptoms of inattention and
hyperactivity and impulsivity are seriously disrupting
the lives of children at home, at school and in the
community.1
There is not just one single cause: ADHD is almost
certainly the result of a combination of factors, and
this combination will vary from child to child.
How common is ADHD?
Sex Differences
ADHD is more common in boys than in girls, with a ratio
of approximately 4 boys to 1 girl.4
Practical Point:
ADHD affects 5%
of school-age ch
ildren. 1,4
This means that
the average UK
cl
as
will include at le
sroom
ast one child wit
h
A
D
HD.
The more seriou
s cases that qual
ify as
hyperkinetic diso
rder affect abou
t 1.5%
of primar y scho
ol children. 1,4
In the UK, not al
l of these childre
n will have
been investigat
ed and diagnose
d.
7
Background to ADHD
The role of genes
Brain processes
• S
tudies of twins suggest that 65%-90% of the risk
of having ADHD is associated with a person’s genes.1
This means that ADHD is often inherited and tends
to run in families.
Brain scan studies have found subtle but distinct
differences between the brains of people with and
without ADHD,1 in their structure, the way in which
they develop and the ways that they work.
•
Specific genes have been linked to ADHD. People
with these genes don’t all have ADHD, but they are
more likely to have it than people without these
genes. Many of these genes have to do with action
of the neurotransmitters* dopamine and
noradrenaline. The main medical treatments
for ADHD boost the function of dopamine and
noradrenaline.1
Other problems
The role of other factors
•Anxiety and depression. Children with ADHD often
have low self-esteem or feel insecure because of
failures at school or in making friends.
Some factors in the child’s development may increase
the chances of having ADHD, but are not the whole
cause of the problem. These include:1
Unfortunately, children with ADHD often have other
problems too. These might include:1
•Conduct disorder (persistent lying, stealing, truancy,
vandalism etc) and oppositional defiant disorder
(persistent and abnormally uncooperative and
defiant behaviour).
•Problems with language, reading and writing.
•Difficult or complicated labour.
•Clumsiness.
•Low birth weight.
•Tic disorders.
•Mother using benzodiazepines,† smoking or drinking
excessive alcohol during pregnancy.
There is also a link between ADHD in children and
delinquency and academic underachievement in
adolescents and young adults.3,4
•Brain diseases and injuries.
* Neurotransmitters are substances that transmit nerve impulses from one nerve cell to another.
† Tranquillizers such as diazepam and temazepam.
www.livingwithadhd.co.uk
9
Identification and diagnosis:
The teacher’s role
• Who does what and when?
• The role of teachers.
The referral process
ADHD is diagnosed by specialists. However, different
professions play a key role in the referral to specialist
services.
The doctor may ask the parent and/or child to fill in
a short questionnaire to give a clearer picture of the
child’s problems.
The GP also plays a key role in the referral process.
If they suspect ADHD, the GP might ask about:
•The child’s behaviour (is (s)he easily distracted, does
(s)he finish things (s)he started, does (s)he fidget a
lot, can (s)he wait her/his turn etc).
• How long the problems have lasted.
• When the problems started.
•How the child’s behaviour is affecting life at home
and at school.
To check for other causes of the problem, the
consultation could also include a physical examination,
a test of hearing and questions about how much sleep
the child is getting.
www.livingwithadhd.co.uk
t
Practical poin
HD as it often
rst to spot AD
fi
e
th
e
b
ay
he first
Teachers m
ool success. T
h
sc
to
r
e
ri
ar
the
represents a b
m teachers is
o
o
sr
as
cl
r
fo
al
NCO)
point of referr
ordinator (SE
o
C
s
d
e
e
N
al
tion
there are
Special Educa
in areas where
t
n
e
al
iv
u
q
e
utside
(or nearest
n refer on to o
e
th
n
ca
o
h
w
rtant to
no SENCOs),
arly it is impo
le
C
.
e
at
ri
p
ro
.
p
an early stage
agencies if ap
at
rs
re
ca
r
o
ts
en
involve the par
The specialist team
The medical specialists who work in ADHD are child
psychiatrists and paediatricians. They work in a team
with other health professionals such as specialist
nurses and psychologists.
At the first appointment, the specialist may not start
a full assessment. In some cases, they may judge that
some advice and support may be enough to improve
things. If this doesn’t work, then a full assessment will
be needed.
– What he thinks about his problems and how
he copes.
The specialist team may ask you for this information
on the phone, in a written report, or in a questionnaire.
As part of the assessment, the parents and the child
may be asked to complete questionnaires to get a fuller
picture of the symptoms.
A full assessment will probably be spread over more
than one appointment and involve more than one
member of the specialist team.
Practical poin
A full assessment should usually include:
Contact with
• A physical examination, vision and
hearing check.
•An interview with the parents covering the child’s
symptoms and medical history.
• An interview with the child, covering:
– H
ow he gets on in the family, at school and
with friends.
– Whether he seems depressed or anxious.
t
the school or
pre-school
Knowledge ab
out how the ch
ild behaves an
away from hom
d performs
e is crucial to th
e diagnosis of
With the perm
ADHD.
ission of the p
arents, the spec
may contact th
ialist team
e school (or pre
-school) to ask
• Behaviour an
about:
d behavioural
problems.
• The child’s le
vel of develop
ment.
• Social funct
ioning.
• Symptoms
of other possib
le disorders.
• Relationship
with the teach
er.
• How the teac
her manages th
e child’s proble
ms.
11
Treatment:
Advice and support
Advice, information and support for children, parents and teachers is an important
part of ADHD treatment.
As a minimum, the specialist team should
develop an understanding of the child’s
problem and offer advice, support and lots
of information about ADHD to the child,
the parents and the teachers.
advice, support and behavioural programme is the best
way to manage the full range of problems experienced
by those with ADHD.2 However, the extent to which this
is possible will vary from region to region based on local
resources and expertise.
Treatment options
All these approaches work in many cases. None of them
work in every case. If one approach doesn’t work, the
specialist is likely to try another.
Other treatments depend on the individual case.
Treatment is likely to include:2,4
• A
structured advice, support and behavioural
programme for parents and/or the child and/
or teachers including specific training on the
management of the child’s behaviour.
• Medication.
Medication should only be prescribed following
assessment by a specialist in ADHD. If symptoms
are mild or temporary, medication may not be
needed at all. In many cases it is recommended that
a combination of both medication and a structured
www.livingwithadhd.co.uk
Some children may also be able to work one-to-one
with a therapist, to develop techniques for monitoring
their own behaviour and controlling it better.
Help with other problems
ADHD seldom occurs without other problems, and
specific help may be offered for these:
• T
raining in social skills to help children make
and keep relationships and avoid aggressive behaviour.
• Counselling to improve self-esteem.
• Remedial teaching.
Practical poin
Structured a
d
t
vice, support
and behavio
ural program
ADHD isn’t ca
mes
used by bad p
arents or bad
research has
te
ac
shown that st
hers, but
ructured prog
and support fo
rammes of ad
r parents and
vice
teachers can
behaviour an
improve the ch
d concentratio
ild’s
n.
Psychologists
work with par
ents and teac
in groups. The
hers individual
y help them to
ly or
:
•Consider cl
assroom stru
cture and task
having the ch
demands (e.g
ild seated clo
.
se to the teac
assignments,
her, brief acad
interspersing
emic
classroom lect
periods of exe
ures with brie
rcise).
f
•Focus on p
articular prob
le
m
times or situat
mealtimes, ge
ions (e.g.
tting ready fo
r school, start
and track the
o
f
the lesson)
child’s behavio
ur over time.
•Work out in
advance what
to do when a
well or badly –
child behaves
then do it con
sistently.
•Develop te
chniques for
getting a child
contact, one
to listen (e.g.
thing at a tim
eye
e, what to do
not to do).
rather than w
hat
• Use token
systems and co
ntracts.
• Use ‘time o
ut’ as a sanctio
n.
13
Medication
• What specialists prescribe.
• What side-effects to look out for.
• Guidance on the question of drug abuse.
Main agents
The medicines licensed in the UK for ADHD are:3
Atomoxetine is also taken once or twice daily.8 While
these drugs frequently provide effective treatment they
also have side-effects.
• Methylphenidate
• Dexamfetamine
• Atomoxetine
Methylphenidate and dexamfetamine belong to
the same class of medicines, called stimulants.1
Atomoxetine is a selective noradrenaline reuptake
inhibitor.3
The development of long-acting medicines
The effect of methylphenidate lasts only for a few hours,
so more than once daily dosing is recommended.1
Three longer acting once-daily preparations of
methylphenidate lasting for between 8 and 12 hours
(equivalent to methylphenidate two or three times
daily)6,7,9 are currently available in the UK.
www.livingwithadhd.co.uk
Practical point
For the child, long-acting medications
may avoid
embarrassment and increase privacy at
school,
and may make it more likely that they
will take the
medicine as prescribed. For the school,
not having
to dispense a medication is a great adv
antage.1
However, once-daily dosing may redu
ce dose
flexibility and tailoring at different time
s of the day.
Note – There is no standard dose of thes
e
medicines – the best dose varies from
child to
child. Normally the specialist will start
with a low
dose and gradually increase it, looking
for the best
balance between effectiveness and side
-effects.
At this stage, parents and teachers may
be asked
to monitor the child’s behaviour quite
intensively
using standard questionnaires.
Treatment expectations
Length of treatment
It is important to understand the potential benefits and
limitations of medical treatment for ADHD.
How long will the child need medication for ADHD?
•Treatment can greatly improve the symptoms of the
child’s ADHD, but cannot cure it completely.
•The child’s doctor will be able to discuss the best
treatment based on their individual needs.
This is not fixed in advance. It may need to continue
for years, and some adults are helped by medication1
(although these medications are not licensed for use
in adults). Medication should be stopped periodically
(for example, once a year) to see how the child gets on
without it.
Side effects that may occur with medication for ADHD
include disturbed sleep, less appetite, stomach upset
and headache, although other may also occur.
For a full list of possible side effects please speak
to a health professional.
It may take some time to find the best dose of drug
treatment to use for the child. The specialist may
prescribe a low dose to begin with, then increase it,
aiming to achieve symptom relief while minimising.
During the early stages of treatment, you may be asked
to help monitor the child’s symptoms using forms
provided to you, and to look out for side effects.
15
Medication
Does the use of methylphenidate and dexamfetamine in childhood increase the chances that a child will become
addicted to similar drugs, or other drugs, in later life? This question naturally worries many parents, teachers and
health professionals. More research needs to be done here before we can answer this with certainty. However we
know that having ADHD increases1 the risk of substance abuse (drugs and alcohol) in later life.
Overall, the studies that have been done suggest that stimulants do more good than harm in this area. In young
people with ADHD treated with stimulants, the risk of substance abuse is almost halved compared with those not
treated with stimulants.1
As always, if you have any concerns about a child’s health or medication, you should consult a specialist
or general practitioner.
Practical point
Stimulants and Drug abuse
In the UK, methylphenidate and dexamf
etamine
are controlled drugs. Taken by mouth
,
methylphenidate is no good as a recreati
onal
drug, but there are some cases of it bein
g
diverted for illicit use by intravenous inje
ction.1
Once-daily formulations mean that chil
dren
do not have to bring medications to sch
ool.
The once-daily preparations are much
more
difficult to grind up or snort.10
www.livingwithadhd.co.uk
Dietary
approaches
Parents often feel that diet plays a role in their child’s ADHD.
The possible role of foods or additives (such as sugar,
artificial colourings and preservatives) in causing
behavioural disorders in children, particularly ADHD,
has been a controversial subject.2
Published evidence suggests that while particular foods or
additives don’t cause ADHD in most cases, in some cases
ADHD patients have specific reactions to particular foods
that can play a role for them. Furthermore a recent carefully
designed trial showed that a combination of artificial
colourings and preservatives significantly increased levels
of ADHD symptoms in the general population.11
The role of omega-3 fatty acids (important for brain
development and function) in improving the symptoms
of ADHD has been investigated in recent years. Dietary
supplementation with fish oils (providing EPA and DHA)
appears to alleviate ADHD-related symptoms at least
in some children.12
A food diary is one way of trying to find out whether
there is any link between behaviour and food in an
individual child.1
Elimination diets (i.e. avoiding specific foods) are
sometimes recommended by specialists, although
these may turn out to be effective for a minority
of children only.1
17
t
n
e
m
t
a
e
r
T
*
s
n
o
i
t
a
d
n
Recomme
h
g people wit
n and youn
re
ve
ild
si
h
n
c
e
r
h
fo
re
t
en
mp
Drug treatm lways form part of a co
ioural
r
a
o
ld
gical, behav
ts
u
n
lo
o
o
re
h
a
sh
c
p
D
r
sy
H
e
p
D
ff
s
o
A
e
d
ld
lu
u
c
o
ls sh
to a
lan that in
entions.
professiona n with ADHD a referral
treatment p
e and interv
c
Healthcare
vi
e
re
d
a
lin
ild
l
ta
h
c
rs
n
l
fi
o
o
ti
e
hildren
as th
-scho
and educa
de to treat c hcare
programme
carers of pre
a
n
y
m
io
d
n
a
at
e
e
c
e
lr
u
b
a
d
s
t
o
alt
ing/e
ision ha
arers have n
h drugs, he
parent-train
When a dec
h ADHD wit
parents or c
mme has
it
e
ra
w
g
th
le
ro
if
p
p
t
o
n
e
e
e
p
th
treatm
mme or
or young
ld consider:
ch a progra
ionals shou
ss
attended su
fe
gnificant
ro
p
D without si
effect.
H
D
d
D
e
H
A
it
D
r
A
lim
fo
t
u
a
te
o
d
ab
ha
henida
ed training
•methylp
have receiv
havioural
e
o
b
h
w
e
ity
duct
d
rs
id
vi
e
rb
h
ro
o
c
p
Tea
com
morbid con
nd
should
o
a
c
t
n
n
h
e
re
it
m
w
ild
e
h
D
g
c
H
a
elp
r AD
and its man
ssroom to h
henidate fo
•methylp
ns in the cla
o
ti
n
e
rv
te
in
D.
disorder
te
le with ADH
hen tics,
has modera
moxetine w
young peop
D
to
t
H
a
D
r
A
o
h
te
it
a
w
on
er, stimulan
be
henid
r young pers
•methylp
nxiety disord
arers should
a
c
t
,
r
n
e
o
se
m
ts
re
ro
n
p
d
e
n
ar
If the child o
tte’s sy
t, the p
cation
rsion are
n
u
e
re
e
d
u
iv
d
/e
To
rm
t
g
ai
n
in
p
la
n
u
im
ai
levels of
sk of stim
up parent-tr
ied and
a group
misuse or ri
rral to a gro
has been tr
gether with
te
to
a
r
id
o
n
n
e
w
offered refe
h
y
o
p
p
s
yl
rated dose,
ioural thera
, either on it
tine if meth
aximum tole
m
e
programme ramme (cognitive behav ild or
•atomoxe
th
t
a
t to low or
ffective
rog
is intoleran
g) for the ch
as been ine
n
h
o
in
n
rs
treatment p
ai
e
p
tr
s
g
n
ill
or you
r social sk
nidate.
or the child
[CBT] and/o
f methylphe
o
s
se
o
.
re
d
n
ve
o
te
h se
modera
young pers
g people wit firstn and youn
e
re
th
ild
s
h
a
c
d
e
re
g
In school-a
ould be offe
uptreatment sh ld also be offered a gro
g
ru
d
,
D
H
D
u
A
sho
nt. Parents
ramme.
line treatme aining/education prog
t-tr
based paren
* Taken from NICE Clinical Guideline 72. Diagnosis and management of ADHD in children, young people and adults. Sept 2008.
Quick reference guide pp5-6 - Available at http://guidedance.nice.org.uk/CG72/QuickRefGuide/PDF/English.
www.livingwithadhd.co.uk
Practical point
Tips for teachers
Children with ADHD have difficulty
with
planning activities and doing them in
the
right order. It’s helpful to give an overvie
Don’t take it personally. There is a med
w
ical of what you want them to ach
ieve: “You’re
reason for much of the child’s behavio
ur.
going to write a review of a book” The
n
A reason is not an excuse. ADHD is the
break it into smaller steps: “First I’d like
you
reason for unacceptable behaviour, but
to choose a book…” etc. A written che
not
cklist
an excuse for it. With your help, children
can be useful. Some children find it use
ful
with ADHD can learn to control their
to say out loud what they are going to
do
behaviour better.
next. Children with ADHD need practice
in
plan
ning and sequencing activities.
Keep in contact with the parents so
that
you know each other’s problems and
Beware of changes to routine and
share
the same approach.
changes of activity. Children with ADHD
may
find these particularly unsettling. Explain
Sit the child close to you. Ideally put
them in advance wha
t’s going to happen if it’s
between two calm and well-behaved pup
ils, different to what they
expect.
and away from doors, windows and oth
er
potential distractions.
Improve their self-esteem by praising
them
in public for good behaviour and
Provide legitimate opportunities to
be
repr
ima
nding them quietly, one-to-one.
physically active. Let them be the one
to
go and fetch something or wipe the boa
Teasing and bullying by other pupils may
rd.
be
a
problem, inside and outside the classroo
Try to find them a way to allow them
m.
to
Setting children with ADHD up with an
fidget, without driving you and everyon
olde
r
e
“buddy” who can help to keep them out
else crazy. Squeeze balls are at least quie
of
t.
trouble may be helpful in some cases.
19
www.livingwithadhd.co.uk
Other useful
information
Support Group
This group provides advice, information and support to individuals and families, and also promote better
awareness of ADHD.
ADDISS - ADHD Information Services
2nd Floor, Premier House
112 Station Road
Edgware, HA8 7BJ
Phone: 020 8952 2800
www.addiss.co.uk
[email protected]
Other resources
Website
www.livingwithadhd.co.uk
www.mentalhealth.org.uk
www.chadd.org
www.adders.org
www.teachernet.gov.uk
Book
Fintan O’Regan. How to teach and manage children with ADHD. (2002) LDA, Wisbech.
21
References
1.Taylor E, et al. European clinical guidelines for hyperkinetic disorder – first upgrade. European Child & Adolescent
Psychiatry. 2004; 13(Suppl 1): 7-30.
2.Scottish Intercollegiate Guidelines Network. Attention deficit and hyperkinetic disorders in children and young people.
October 2009. www.sign.ac.uk.
3.NICE. Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD)
in children and adolescents. March 2006. www.nice.org.uk.
4.NICE. Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in children, young people and adults.
March 2009. www.nice.org.uk.
5.Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. American Psychiatric Association, 2000.
6.Concerta® XL. Summary of Product Characteristics. Janssen-Cilag Ltd. November 2009. www.emc.medicines.org.uk.
7.Equasym XL™. Summary of Product Characteristics. Shire Pharmaceuticals Ltd. June 2009. www.emc.medicines.org.uk.
8.Strattera®. Summary of Product Characteristics. Lilly. May 2009. www.emc.medicines.org.uk.
9.Medikinet®. Summary of Product Characteristics. Flynn pharma.
Feb 2007. www.emc.medicines.org.uk.
10. A
ACAP. Practice parameter for the use of stimulant medications in the treatment
of children, adolescents and adults. J Am Acad Child Adolesc Psychiatry 2002;
41(2 Suppl): 26S-49S.
11. M
cCann, D et al. Food additives and hyperactive behaviour in 3-year-old
and 8/9-year-old children in the community: a randomised, doubleblinded, placebo-controlled trial. Lancet 2007; 370; 9598: 1560-1567.
12. R
ichardson AJ. Omega-3 fatty acids in ADHD and related
neurodevelopmental disorders. Int Rev Psychiatry 2006;
18(2): 155-172.
www.livingwithadhd.co.uk
Notes
23
Provided as a service to medicine by
Item number: CON/10-0117-615519
Date of preparation: July 2013