This document summarizes a seminar on attention deficit hyperactivity disorder (ADHD). It discusses the definition and diagnostic criteria for ADHD, epidemiology including prevalence and gender differences, comorbidities, risk factors including strong genetic heritability, and environmental influences. Treatment options and long term outcomes are also reviewed. The seminar aims to inform clinicians on current understanding and controversies regarding ADHD.
Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE): ...BARRY STANLEY 2 fasd
Neurobehavioral Disorder Associated with Prenatal Alcohol
Exposure (ND-PAE): Proposed DSM-5 Diagnosis
Julie A. Kable1,Mary J. O’Connor2, Heather Carmichael Olson3, Blair Paley2, Sarah N. Mattson4, Sally M. Anderson5, Edward P. Riley.
Abstract Over the past 40 years, a significant body of
animal and human research has documented the teratogenic
effects of prenatal alcohol exposure (PAE). Neurobehavioral
Disorder associated with PAE is proposed as a new
clarifying term, intended to encompass the neurodevelopmental
and mental health symptoms associated with PAE.
Defining this disorder is a necessary step to adequately
characterize these symptoms and allow clinical assessment
not possible using existing physically-based diagnostic
schemes. Without appropriate diagnostic guidelines,
affected individuals are frequently misdiagnosed and treated
inappropriately (often to their considerable detriment)
by mental health, educational, and criminal justice systems.
Three core areas of deficits identified from the available
research, including neurocognitive, self-regulation, and
adaptive functioning impairments, are discussed and
information regarding associated features and disorders,
prevalence, course, familial patterns, differential diagnosis,
and treatment of the proposed disorder are also provided.
The utility of psychotropic drugs on patients with fetal alcohol spectrum dis...BARRY STANLEY 2 fasd
ABSTRACT
BACKGROUND: Treatment of the complications arising from Prenatal Alcohol Exposure (PAE) has largely been focused on psychosocial and environmental approaches. Research on the
use of medications, especially psychotropic medications, has lagged behind.
OBJECTIVES: This systematic review sought to investigate psychotropic medication related findings and outcomes in those diagnosed with Fetal Alcohol Spectrum Disorder (FASD).
METHODS: Comprehensive searches were conducted in seven major databases (Medline/
PubMed, Scopus, Web of Knowledge, Embase, PsycINFO, Cochrane Library, and
PsycARTICLES) up to February 2017. Key search terms with synonyms were mapped on these databases. There were no timeline restrictions and no grey literature searches. Two reviewers
independently assessed 25 studies that met the inclusion criteria. Most studies were reviews of treatment and retrospective case series.
RESULTS: Two crossover randomized trials were reported, and the findings were not amenable to meta-analysis. Several conditions (depression, agitation, seizures, and outburst) combined with the most frequent presentation, ADHD, to represent the rationale for prescribing psychotropic medications. Second-generation antipsychotics were found to improve social skills, but the paucity of data limited the extent of clinical guidance necessary for the field.
CONCLUSIONS: The systematic review showed that there are some clinical evidence displaying
the validity of psychopharmacological interventions in people with FASD, which varies across the spectrum of disease severity, age, and gender. There is a need for more clinical evidencebased studies in addition to clinical expert opinions to substantiate an optimal ground for individualized management of FASD.
The study protocol for this review was registered in PROSPERO with registration number
CRD42016045703
Psychiatric concerns about the consequences of prenatal alcohol exposureBARRY STANLEY 2 fasd
Psychiatric concerns about the consequences of prenatal alcohol exposure
I have omitted the references in these papers. They can be downloaded.
In 2014 the US National Institute of Mental Health (NIMH) announced it was going to divert research funding from abstract psychiatry to the neurobiological roots of disease.
This has resulted in identification of the abnormal brain functions relating to the behavioral diagnoses of the DSM5. These brain disfunctions are not the cause of DSM5 mental illnesses: they are the true pathology of those mental illnesses. The question is- what is the cause of those brain disfunctions?
Psychiatry has never explored the role of prenatal alcohol, or preconceptual alcohol in the etiology of mental illnesses.
This is in spite of anecdotal, behavioral, epidemiological, neurological and epigenetic correlations.
Meanwhile mental illness, addictions and suicides continue unabated, in spite of huge expenditures.
The day will come when the genes that control individual aspects of brain function will be identified. Changes in gene expression will be related to clinical presentations, such as those in the DSM5: the generation at which those changes occurred will be determined.
The agent that caused those changes, with other environmental factors, will be identified.
Then we will understand to what degree alcohol has determined the nature of mental illness.
Name Professor Course Date Sexual Harassment .docxroushhsiu
Name
Professor
Course
Date
Sexual Harassment Essay Outline
I. Introduction
A. Background
1. Despite ongoing public campaigns designed to prevent sexual harassment,
this destructive behavior continues to be a widespread issue in the United
States. Sexual harassment is particularly rampant on college campuses,
where 62% of female students and 61% of male students report having
been victims of this form of mistreatment, according to the AAUW
Educational Foundation. Most of the harassment is noncontact, but about
one-third of students are victims of physical harassment.
B. Thesis Statement
1. Although mass media and news outlets alike tend to shy away from the
sexual harassment problem occuring across our campuses nationwide,
universities are failing to protect their students from sexual harassment
resulting in mental health damage of both males and females in all parts of
the nation
II. Body
A. Sexual Harassment Amongst Both Genders
1. Female Sexual Harassment In Comparison
a) Statistics Regarding Harassment Committed Against
b) General Concerns Over Safety Amongst Females
2. Male Sexual Harassment In Comparison
a) Statistics Regarding Harassment Committed Against
b) Lack of Awareness That Men Can Also Experience Harassment
On College Campuses
B. Sexual Harassment Being Neglected Nationwide
1. Lack of Media Coverage & Lack of Awareness
a) Disregard Of A Widespread Issue Going On In Our Nation
b) People Not Taking Sexual Harassment Seriously/Not Being Aware
of It
2. Lack of Knowledge Regarding Universities Legal Duty to Protect
Students
a) Title XI Law of 1972
b) Title VII of the Civil Rights Act of 1964
C. Sexual Harassment’s Effect on Students Experiencing It
1. Short Term Mental Effects
a) People Disregarding and Neglecting People Who Claim Sexual
Harassment Can Cause Them Insecurity and Hopelessness
b) People Tend To Blame Themselves For Being Harrassed
2. Long Term Mental Effects
a) Depression and Inability To Trust Others
b) Can Lead To Drastic Effects Like Turning To Drugs Or
Committing Suicide, It is Afterall A Form Of Bullying
III. Conclusion
A. The failure of our nations awarness and our universities inability to abide to the
law by protecting our students has resulted in many students being permanently
damaged from sexual harassment
B. We the people of the United States have gone through all the proper legal
measures in order to guarantee the youths safety when attending college
universities; yet these laws along with their $60,000 tuitions do not seem to be
enough motivation for these universities to abide to the law. Does a student need
to be found dead in the middle of the campus in order to get the message across?
Psychiatric Diagnostic Screening Questionnaire
Review of The Psychiatric Diagnostic Screening Questionnaire by MICHAEL G. KAVAN, Associate Dean for Student Affairs and Associate Professor of Family Medicine, Creighton University Sch ...
Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE): ...BARRY STANLEY 2 fasd
Neurobehavioral Disorder Associated with Prenatal Alcohol
Exposure (ND-PAE): Proposed DSM-5 Diagnosis
Julie A. Kable1,Mary J. O’Connor2, Heather Carmichael Olson3, Blair Paley2, Sarah N. Mattson4, Sally M. Anderson5, Edward P. Riley.
Abstract Over the past 40 years, a significant body of
animal and human research has documented the teratogenic
effects of prenatal alcohol exposure (PAE). Neurobehavioral
Disorder associated with PAE is proposed as a new
clarifying term, intended to encompass the neurodevelopmental
and mental health symptoms associated with PAE.
Defining this disorder is a necessary step to adequately
characterize these symptoms and allow clinical assessment
not possible using existing physically-based diagnostic
schemes. Without appropriate diagnostic guidelines,
affected individuals are frequently misdiagnosed and treated
inappropriately (often to their considerable detriment)
by mental health, educational, and criminal justice systems.
Three core areas of deficits identified from the available
research, including neurocognitive, self-regulation, and
adaptive functioning impairments, are discussed and
information regarding associated features and disorders,
prevalence, course, familial patterns, differential diagnosis,
and treatment of the proposed disorder are also provided.
The utility of psychotropic drugs on patients with fetal alcohol spectrum dis...BARRY STANLEY 2 fasd
ABSTRACT
BACKGROUND: Treatment of the complications arising from Prenatal Alcohol Exposure (PAE) has largely been focused on psychosocial and environmental approaches. Research on the
use of medications, especially psychotropic medications, has lagged behind.
OBJECTIVES: This systematic review sought to investigate psychotropic medication related findings and outcomes in those diagnosed with Fetal Alcohol Spectrum Disorder (FASD).
METHODS: Comprehensive searches were conducted in seven major databases (Medline/
PubMed, Scopus, Web of Knowledge, Embase, PsycINFO, Cochrane Library, and
PsycARTICLES) up to February 2017. Key search terms with synonyms were mapped on these databases. There were no timeline restrictions and no grey literature searches. Two reviewers
independently assessed 25 studies that met the inclusion criteria. Most studies were reviews of treatment and retrospective case series.
RESULTS: Two crossover randomized trials were reported, and the findings were not amenable to meta-analysis. Several conditions (depression, agitation, seizures, and outburst) combined with the most frequent presentation, ADHD, to represent the rationale for prescribing psychotropic medications. Second-generation antipsychotics were found to improve social skills, but the paucity of data limited the extent of clinical guidance necessary for the field.
CONCLUSIONS: The systematic review showed that there are some clinical evidence displaying
the validity of psychopharmacological interventions in people with FASD, which varies across the spectrum of disease severity, age, and gender. There is a need for more clinical evidencebased studies in addition to clinical expert opinions to substantiate an optimal ground for individualized management of FASD.
The study protocol for this review was registered in PROSPERO with registration number
CRD42016045703
Psychiatric concerns about the consequences of prenatal alcohol exposureBARRY STANLEY 2 fasd
Psychiatric concerns about the consequences of prenatal alcohol exposure
I have omitted the references in these papers. They can be downloaded.
In 2014 the US National Institute of Mental Health (NIMH) announced it was going to divert research funding from abstract psychiatry to the neurobiological roots of disease.
This has resulted in identification of the abnormal brain functions relating to the behavioral diagnoses of the DSM5. These brain disfunctions are not the cause of DSM5 mental illnesses: they are the true pathology of those mental illnesses. The question is- what is the cause of those brain disfunctions?
Psychiatry has never explored the role of prenatal alcohol, or preconceptual alcohol in the etiology of mental illnesses.
This is in spite of anecdotal, behavioral, epidemiological, neurological and epigenetic correlations.
Meanwhile mental illness, addictions and suicides continue unabated, in spite of huge expenditures.
The day will come when the genes that control individual aspects of brain function will be identified. Changes in gene expression will be related to clinical presentations, such as those in the DSM5: the generation at which those changes occurred will be determined.
The agent that caused those changes, with other environmental factors, will be identified.
Then we will understand to what degree alcohol has determined the nature of mental illness.
Name Professor Course Date Sexual Harassment .docxroushhsiu
Name
Professor
Course
Date
Sexual Harassment Essay Outline
I. Introduction
A. Background
1. Despite ongoing public campaigns designed to prevent sexual harassment,
this destructive behavior continues to be a widespread issue in the United
States. Sexual harassment is particularly rampant on college campuses,
where 62% of female students and 61% of male students report having
been victims of this form of mistreatment, according to the AAUW
Educational Foundation. Most of the harassment is noncontact, but about
one-third of students are victims of physical harassment.
B. Thesis Statement
1. Although mass media and news outlets alike tend to shy away from the
sexual harassment problem occuring across our campuses nationwide,
universities are failing to protect their students from sexual harassment
resulting in mental health damage of both males and females in all parts of
the nation
II. Body
A. Sexual Harassment Amongst Both Genders
1. Female Sexual Harassment In Comparison
a) Statistics Regarding Harassment Committed Against
b) General Concerns Over Safety Amongst Females
2. Male Sexual Harassment In Comparison
a) Statistics Regarding Harassment Committed Against
b) Lack of Awareness That Men Can Also Experience Harassment
On College Campuses
B. Sexual Harassment Being Neglected Nationwide
1. Lack of Media Coverage & Lack of Awareness
a) Disregard Of A Widespread Issue Going On In Our Nation
b) People Not Taking Sexual Harassment Seriously/Not Being Aware
of It
2. Lack of Knowledge Regarding Universities Legal Duty to Protect
Students
a) Title XI Law of 1972
b) Title VII of the Civil Rights Act of 1964
C. Sexual Harassment’s Effect on Students Experiencing It
1. Short Term Mental Effects
a) People Disregarding and Neglecting People Who Claim Sexual
Harassment Can Cause Them Insecurity and Hopelessness
b) People Tend To Blame Themselves For Being Harrassed
2. Long Term Mental Effects
a) Depression and Inability To Trust Others
b) Can Lead To Drastic Effects Like Turning To Drugs Or
Committing Suicide, It is Afterall A Form Of Bullying
III. Conclusion
A. The failure of our nations awarness and our universities inability to abide to the
law by protecting our students has resulted in many students being permanently
damaged from sexual harassment
B. We the people of the United States have gone through all the proper legal
measures in order to guarantee the youths safety when attending college
universities; yet these laws along with their $60,000 tuitions do not seem to be
enough motivation for these universities to abide to the law. Does a student need
to be found dead in the middle of the campus in order to get the message across?
Psychiatric Diagnostic Screening Questionnaire
Review of The Psychiatric Diagnostic Screening Questionnaire by MICHAEL G. KAVAN, Associate Dean for Student Affairs and Associate Professor of Family Medicine, Creighton University Sch ...
11. Identifying the Elements of the Limitations & ImplicationsGo tBenitoSumpter862
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
11. Identifying the Elements of the Limitations & ImplicationsGo tSantosConleyha
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
Neurobehavioral disorder associated with prenatal alcohol exposureBARRY STANLEY 2 fasd
Children and adolescents affected by prenatal exposure to alcohol who have brain damage that is manifested in functional impairments of neurocognition, self-regulation, and adaptive functioning may most appropriately be diagnosed with neurobehavioral disorder associated with prenatal exposure. This Special Article outlines clinical implications and guidelines for pediatric medical home clinicians to identify, diagnose, and refer children regarding neurobehavioral disorder associated with prenatal exposure. Emphasis is given to reported or observable behaviors that can be identified as part of care in
pediatric medical homes, differential diagnosis, and potential comorbidities. In addition, brief guidance is provided on the management of affected children in the pediatric medical home. Finally, suggestions are given for obtaining prenatal history of in utero exposure to alcohol for the pediatric patient.
ADHD and Addiction: Diagnosis and ManagementJacob Kagan
Presentation by Jacob Kagan MD on the diagnosis and management of ADHD and Substance Abuse Disorders, including epidemiology and comorbid conditions,
causality and functional impact, potential explanations for the ADHD/SUD association,stimulant treatment and the risk for SUDs, diversion and misuse of stimulant medications, and treatment recommendations. http://jacobkaganmd.com
Genetics of attention deficit hyperactivity disorder (adhd)Joy Maria Mitchell
Attention deficit hyperactivity disorder (ADHD) is a developmental disorder. ADHD is the commonly studied and
diagnosed as psychiatric disorder. Here we shall see the relation between extraversion and ADHD, neuroticism,
biological relation, Environmental factors and with diagnosis of ADHD. It is known that Genetics is one of the factors
that may contribute to, or exacerbate ADHD. Recent research probing towards the environmental and Genetic factors
causing ADHD differences is the main source for investigation
Running head: SCHIZOPHRENIA 1
Working with Families
1. Effects of a psych educational intervention program on the attitudes and health perceptions of relatives of patients with schizophrenia
The article highlights the importance of both family and relatives to support the victim who has schizophrenia. Moreover, the article goes further and highlights the purpose of the study. The article assesses the effectiveness of a family psych educational program in the different outlook and health insights of the relatives of the patient with suffering from schizophrenia. Various programs aid in supporting both the family and relatives to gain more information about the schizophrenia and how they can best offer support to them.
The psych educational program was efficient in adjusting to the caregivers’ outlooks. Nonetheless, the program did not influence the perceptions of healthcare. Moreover, the family and relative psych educational management program transforms the deleterious approaches of both family and relatives to schizophrenia. On the other hand, not all the agenda of this type may advance health difficulties; otherwise, their consequences might only appear in a long-term condition or situation.
The psycho-educational plan gave an enhancement in the outlooks of families to schizophrenia. Besides, this signifies that they have known how to think, feel, and act, in a positive method in regards to the disorder.
Seeing the unfortunate result of the majority of people who have schizophrenia, the process has made it possible for individuals to discover the influence of psych educational programs, which may aid indirectly or directly to advancing the quality and the course of life of these people and their families. Besides, it is vital to evaluate the efficiency of the agendas in diverse cultures and nations.
2. The Mediating Effect of Family Cohesion in Reducing Patient Symptoms and Family Distress in a Culturally Informed Family Therapy for Schizophrenia: A Parallel-Process Latent-Growth Model
The paper examines whether a CIT-S (Culturally Informed Family Therapy for Schizophrenia outdid the usual family psych education (PSY-ED) by not only in reducing patient schizophrenia signs but also in diminishing a person’s DASS. Since CIT-S nurtured family consistency in therapy; moreover, it is anticipated that an increase in family solidity would facilitate the cure effects.
The procedure permitted individual’s to be fixed in latent-change or latent-growth models to check the treatment impacts and guarantee the model fit was sufficient prior to joining them to parallel-procedure models and investigating the secondary outcomes. The latent-change model is assessing the medication influence on family solidity from standard to average, as shown in a Time Treatment Interaction (TTI). The CIT-S team displayed a natural growth of approximately on.
REVIEWpublished 24 June 2015doi 10.3389fnhum.2015.003.docxmalbert5
REVIEW
published: 24 June 2015
doi: 10.3389/fnhum.2015.00359
Pathophysiology of ADHD and
associated problems—starting points
for NF interventions?
Björn Albrecht*, Henrik Uebel-von Sandersleben, Holger Gevensleben and
Aribert Rothenberger
Department of Child and Adolescent Psychiatry, University Medical Center Göttingen, Göttingen, Germany
Edited by:
Martijn Arns,
Research Institute Brainclinics,
Netherlands
Reviewed by:
Roumen Kirov,
Institute of Neurobiology, Bulgarian
Academy of Sciences, Bulgaria
Leon Kenemans,
Utrecht University, Netherlands
*Correspondence:
Björn Albrecht,
Department of Child and Adolescent
Psychiatry, University Medical Center
Göttingen, von Siebold Straße 5,
37075 Göttingen, Germany
[email protected]
Received: 06 October 2014
Accepted: 02 June 2015
Published: 24 June 2015
Citation:
Albrecht B, Uebel-von Sandersleben
H, Gevensleben H and Rothenberger
A (2015) Pathophysiology of ADHD
and associated problems—starting
points for NF interventions?
Front. Hum. Neurosci. 9:359.
doi: 10.3389/fnhum.2015.00359
Attention deficit hyperactivity disorder (ADHD) is characterized by severe and
age-inappropriate levels of hyperactivity, impulsivity and inattention. ADHD is a
heterogeneous disorder, and the majority of patients show comorbid or associated
problems from other psychiatric disorders. Also, ADHD is associated with cognitive and
motivational problems as well as resting-state abnormalities, associated with impaired
brain activity in distinct neuronal networks. This needs to be considered in a multimodal
treatment, of which neurofeedback (NF) may be a promising component. During NF,
specific brain activity is fed-back using visual or auditory signals, allowing the participants
to gain control over these otherwise unaware neuronal processes. NF may be used
to directly improve underlying neuronal deficits, and/or to establish more general self-
regulatory skills that may be used to compensate behavioral difficulties. The current
manuscript describes pathophysiological characteristics of ADHD, heterogeneity of
ADHD subtypes and gender differences, as well as frequently associated behavioral
problems such as oppositional defiant/conduct or tic disorder. It is discussed how NF
may be helpful as a treatment approach within these contexts.
Keywords: Neurofeedback (NF), ADHD, ODD/CD, tic disorder, comorbidity, children, neurobiology
Introduction
Difficulties with Inattention or Hyperactivity and Impulsivity as the core symptoms of Attention
deficit Hyperactivity disorder (ADHD) are a frequent psychosocial burden. With an early onset
during childhood, ADHD is often persisting throughout life. It is a heterogeneous disorder, and a
challenge to treat. In light of this heterogeneity, the most promising treatment approach should
be multimodal in nature (Taylor et al., 2004; Swanson et al., 2008). Pharmacological interventions
particularly with stimulants such as methylphenidate and amphetamine sulfate, as well as non-
s.
Abstract—Prevalence of degenerative dementias and dementias associated with cerebrovascular disease is increasing with the time. Dementia is one of the most significant public health problems. Demographic data, medical history, general biochemical data and serum total homocysteine (tHcy) levels was used in this study to examine the differences between dementia and normal control groups. A cross-sectional study was conducted on 236 individuals who were above the age of 65 years. These participants went through the Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), demographic characteristics, biochemical data and tHcy level. Each of the above mentioned factors was assessed. There were significant differences in the history of hypertension, diabetes mellitus, marital status, alcohol consumption (AC), BMI value, and triglyceride (TG) and serum tHcy levels. The logistic regression analysis showed significant differences in marital status, AC and tHcy. So it can be concluded that elevated serum tHcy, no AC and no partner are associated with the risk of dementia in elders of Southern Taiwan. It needs further researches to identify and reduce the risk of dementia.
Self-awareness is key to improving your communication skills. Reflec.docxtcarolyn
Self-awareness is key to improving your communication skills. Reflect on your strengths and weaknesses as a communicator (in general - not just with regard to students). What do you do well? What do you need to improve upon? Be specific. Provide examples of each and what you plan to do to improve your communication skills.
.
Self-Assessment Surveys and Development of Leadership Talent P.docxtcarolyn
Self-Assessment Surveys and Development of Leadership Talent" Please respond to the following:
Debate the usefulness of self-assessment surveys to determine employees with high potential within the organization. Create a list of five (5) critical areas in which high-potential candidates would assess themselves to be included in the talent pool for promotion and discuss how you would use the assessment.
Leadership talent is an organization-wide goal. Discuss how the responsibilities of the development of leadership talent should be partitioned among Human Resources staff and line managers. Be sure to address both the identification and development of future leadership.
.
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Similar to Seminar1240 www.thelancet.com Vol 387 March 19, 2016.docx
11. Identifying the Elements of the Limitations & ImplicationsGo tBenitoSumpter862
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
11. Identifying the Elements of the Limitations & ImplicationsGo tSantosConleyha
11. Identifying the Elements of the Limitations & Implications
Go to the Limitations/Implications section(s) and identify the limitations of the study and how those limitations impacted the whole study.
12. Identifying the Elements of the Conclusion Section
Go to the Conclusion section and identify the conclusive statements of the study and the recommendations made for future research.
POST # 1 EDITHA
When assessing an adolescent with bipolar disorder, what are some of the diagnostic and treatment challenges the clinician might face?
Bipolar disorder is a serious mental health disorder that is often first diagnosed during young adulthood or adolescence. Symptoms of the illness, however, also can appear in early childhood. Although once thought rare in children, diagnosis of bipolar disorder in children has significantly increased over the last decade (Papolos & Bronsteen, 2018). Despite the increased diagnosis of bipolar disorder in children, assessment and diagnosis remain challenging and controversial. This is, in part, because of the lack of research on this disorder in children and adolescents and the growing recognition that the disease can present differently in children from how it presents in adults (AACAP, 2019). Over the years, more attention has focused on the unique presentation of bipolar disorder in the young that has introduced new ways of looking at this disease and assessing it in children.
The importance of identifying the presence of bipolar disease at an early age is highlighted by data showing that adults in whom bipolar disease started at an early age have a more severe course of the illness compared with adult-onset disease. Early-onset disease is associated with a higher risk of suicide; severe mood lability and polarity; lower quality of life and greater functional impairment; higher rates of comorbidity; and a higher risk of substance use disorders compared with adult-onset disease (Papolos & Bronsteen, 2018). Although some children meet the criteria established for adults categorized in the DSM-5, many children fall outside these classical categories, and diagnosis in these children is particularly challenging and difficult (APA, 2013). For these children, additional information beyond what is provided in the DSM may help make an accurate diagnosis which causes increased challenges in assessment and diagnosis.
References
Papolos, D, & Bronsteen A. (2018) bipolar disorder in children: assessment in general pediatric practice. Curr Opin Pediatr, 25(3):419-426.
American Academy of Child and Adolescent Psychiatry (AACAP). (2019) bipolar disorder: Parents’ Medication Guide for Bipolar Disorder in Children & Adolescents.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association.
RESEARCH ARTICLE
Association of suicidal behavior with exposure
to suicide and suicide attempt: A systematic
...
Neurobehavioral disorder associated with prenatal alcohol exposureBARRY STANLEY 2 fasd
Children and adolescents affected by prenatal exposure to alcohol who have brain damage that is manifested in functional impairments of neurocognition, self-regulation, and adaptive functioning may most appropriately be diagnosed with neurobehavioral disorder associated with prenatal exposure. This Special Article outlines clinical implications and guidelines for pediatric medical home clinicians to identify, diagnose, and refer children regarding neurobehavioral disorder associated with prenatal exposure. Emphasis is given to reported or observable behaviors that can be identified as part of care in
pediatric medical homes, differential diagnosis, and potential comorbidities. In addition, brief guidance is provided on the management of affected children in the pediatric medical home. Finally, suggestions are given for obtaining prenatal history of in utero exposure to alcohol for the pediatric patient.
ADHD and Addiction: Diagnosis and ManagementJacob Kagan
Presentation by Jacob Kagan MD on the diagnosis and management of ADHD and Substance Abuse Disorders, including epidemiology and comorbid conditions,
causality and functional impact, potential explanations for the ADHD/SUD association,stimulant treatment and the risk for SUDs, diversion and misuse of stimulant medications, and treatment recommendations. http://jacobkaganmd.com
Genetics of attention deficit hyperactivity disorder (adhd)Joy Maria Mitchell
Attention deficit hyperactivity disorder (ADHD) is a developmental disorder. ADHD is the commonly studied and
diagnosed as psychiatric disorder. Here we shall see the relation between extraversion and ADHD, neuroticism,
biological relation, Environmental factors and with diagnosis of ADHD. It is known that Genetics is one of the factors
that may contribute to, or exacerbate ADHD. Recent research probing towards the environmental and Genetic factors
causing ADHD differences is the main source for investigation
Running head: SCHIZOPHRENIA 1
Working with Families
1. Effects of a psych educational intervention program on the attitudes and health perceptions of relatives of patients with schizophrenia
The article highlights the importance of both family and relatives to support the victim who has schizophrenia. Moreover, the article goes further and highlights the purpose of the study. The article assesses the effectiveness of a family psych educational program in the different outlook and health insights of the relatives of the patient with suffering from schizophrenia. Various programs aid in supporting both the family and relatives to gain more information about the schizophrenia and how they can best offer support to them.
The psych educational program was efficient in adjusting to the caregivers’ outlooks. Nonetheless, the program did not influence the perceptions of healthcare. Moreover, the family and relative psych educational management program transforms the deleterious approaches of both family and relatives to schizophrenia. On the other hand, not all the agenda of this type may advance health difficulties; otherwise, their consequences might only appear in a long-term condition or situation.
The psycho-educational plan gave an enhancement in the outlooks of families to schizophrenia. Besides, this signifies that they have known how to think, feel, and act, in a positive method in regards to the disorder.
Seeing the unfortunate result of the majority of people who have schizophrenia, the process has made it possible for individuals to discover the influence of psych educational programs, which may aid indirectly or directly to advancing the quality and the course of life of these people and their families. Besides, it is vital to evaluate the efficiency of the agendas in diverse cultures and nations.
2. The Mediating Effect of Family Cohesion in Reducing Patient Symptoms and Family Distress in a Culturally Informed Family Therapy for Schizophrenia: A Parallel-Process Latent-Growth Model
The paper examines whether a CIT-S (Culturally Informed Family Therapy for Schizophrenia outdid the usual family psych education (PSY-ED) by not only in reducing patient schizophrenia signs but also in diminishing a person’s DASS. Since CIT-S nurtured family consistency in therapy; moreover, it is anticipated that an increase in family solidity would facilitate the cure effects.
The procedure permitted individual’s to be fixed in latent-change or latent-growth models to check the treatment impacts and guarantee the model fit was sufficient prior to joining them to parallel-procedure models and investigating the secondary outcomes. The latent-change model is assessing the medication influence on family solidity from standard to average, as shown in a Time Treatment Interaction (TTI). The CIT-S team displayed a natural growth of approximately on.
REVIEWpublished 24 June 2015doi 10.3389fnhum.2015.003.docxmalbert5
REVIEW
published: 24 June 2015
doi: 10.3389/fnhum.2015.00359
Pathophysiology of ADHD and
associated problems—starting points
for NF interventions?
Björn Albrecht*, Henrik Uebel-von Sandersleben, Holger Gevensleben and
Aribert Rothenberger
Department of Child and Adolescent Psychiatry, University Medical Center Göttingen, Göttingen, Germany
Edited by:
Martijn Arns,
Research Institute Brainclinics,
Netherlands
Reviewed by:
Roumen Kirov,
Institute of Neurobiology, Bulgarian
Academy of Sciences, Bulgaria
Leon Kenemans,
Utrecht University, Netherlands
*Correspondence:
Björn Albrecht,
Department of Child and Adolescent
Psychiatry, University Medical Center
Göttingen, von Siebold Straße 5,
37075 Göttingen, Germany
[email protected]
Received: 06 October 2014
Accepted: 02 June 2015
Published: 24 June 2015
Citation:
Albrecht B, Uebel-von Sandersleben
H, Gevensleben H and Rothenberger
A (2015) Pathophysiology of ADHD
and associated problems—starting
points for NF interventions?
Front. Hum. Neurosci. 9:359.
doi: 10.3389/fnhum.2015.00359
Attention deficit hyperactivity disorder (ADHD) is characterized by severe and
age-inappropriate levels of hyperactivity, impulsivity and inattention. ADHD is a
heterogeneous disorder, and the majority of patients show comorbid or associated
problems from other psychiatric disorders. Also, ADHD is associated with cognitive and
motivational problems as well as resting-state abnormalities, associated with impaired
brain activity in distinct neuronal networks. This needs to be considered in a multimodal
treatment, of which neurofeedback (NF) may be a promising component. During NF,
specific brain activity is fed-back using visual or auditory signals, allowing the participants
to gain control over these otherwise unaware neuronal processes. NF may be used
to directly improve underlying neuronal deficits, and/or to establish more general self-
regulatory skills that may be used to compensate behavioral difficulties. The current
manuscript describes pathophysiological characteristics of ADHD, heterogeneity of
ADHD subtypes and gender differences, as well as frequently associated behavioral
problems such as oppositional defiant/conduct or tic disorder. It is discussed how NF
may be helpful as a treatment approach within these contexts.
Keywords: Neurofeedback (NF), ADHD, ODD/CD, tic disorder, comorbidity, children, neurobiology
Introduction
Difficulties with Inattention or Hyperactivity and Impulsivity as the core symptoms of Attention
deficit Hyperactivity disorder (ADHD) are a frequent psychosocial burden. With an early onset
during childhood, ADHD is often persisting throughout life. It is a heterogeneous disorder, and a
challenge to treat. In light of this heterogeneity, the most promising treatment approach should
be multimodal in nature (Taylor et al., 2004; Swanson et al., 2008). Pharmacological interventions
particularly with stimulants such as methylphenidate and amphetamine sulfate, as well as non-
s.
Abstract—Prevalence of degenerative dementias and dementias associated with cerebrovascular disease is increasing with the time. Dementia is one of the most significant public health problems. Demographic data, medical history, general biochemical data and serum total homocysteine (tHcy) levels was used in this study to examine the differences between dementia and normal control groups. A cross-sectional study was conducted on 236 individuals who were above the age of 65 years. These participants went through the Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), demographic characteristics, biochemical data and tHcy level. Each of the above mentioned factors was assessed. There were significant differences in the history of hypertension, diabetes mellitus, marital status, alcohol consumption (AC), BMI value, and triglyceride (TG) and serum tHcy levels. The logistic regression analysis showed significant differences in marital status, AC and tHcy. So it can be concluded that elevated serum tHcy, no AC and no partner are associated with the risk of dementia in elders of Southern Taiwan. It needs further researches to identify and reduce the risk of dementia.
Similar to Seminar1240 www.thelancet.com Vol 387 March 19, 2016.docx (20)
Self-awareness is key to improving your communication skills. Reflec.docxtcarolyn
Self-awareness is key to improving your communication skills. Reflect on your strengths and weaknesses as a communicator (in general - not just with regard to students). What do you do well? What do you need to improve upon? Be specific. Provide examples of each and what you plan to do to improve your communication skills.
.
Self-Assessment Surveys and Development of Leadership Talent P.docxtcarolyn
Self-Assessment Surveys and Development of Leadership Talent" Please respond to the following:
Debate the usefulness of self-assessment surveys to determine employees with high potential within the organization. Create a list of five (5) critical areas in which high-potential candidates would assess themselves to be included in the talent pool for promotion and discuss how you would use the assessment.
Leadership talent is an organization-wide goal. Discuss how the responsibilities of the development of leadership talent should be partitioned among Human Resources staff and line managers. Be sure to address both the identification and development of future leadership.
.
Self-Assessment PortfolioThis assignment asks you to reflect u.docxtcarolyn
Self-Assessment Portfolio
This assignment asks you to reflect upon your own interpersonal communication skills and evaluate your effectiveness as a communicator in interpersonal situations. There are a variety of self-assessments to choose from and the documents containing these assessments are in a folder on the course CelticOnline page. Choose 10 assessments to complete and make sure to complete the assessment first before reading more about what the assessment attempts to measure. Try to choose a variety of assessments to obtain a well-rounded understanding of your interpersonal communication skills.
After completing the assessments, for each assessment you will need to complete a 2-page assignment in which you need to address the following concerns:
· Description —describe the exercise/assignment using the concepts discussed in class and in the textbook.
· Purpose —identify the purpose of the exercise by relating the exercise to the principles or theories discussed in class, in the textbook, in additional readings, and/or additional information provided about the assessment.
· Analysis —analyze the process of the exercise, i.e., what you learned and how you came to realize key concepts related to the purpose; analyze your strengths and limitations related to this competency.
· Self-Assessment —conclude your report by stating how principles learned can be applied to your personal communication skills and/or your success in interpersonal relationships; what have you learned to help you develop this competency?
I suggest you complete assessments as we cover the corresponding material in class. Additional documents contain original research that cover the purposes and definitions of each assessment.
BE SURE TO GIVE PROPER CITATIONS FOR WORK/IDEAS/CONCEPTS THAT ARE NOT YOUR OWN. Each assignment should have a reference sheet where you site your sources that contributed to your understanding of that assessment.
Your Self-Assessment Portfolio is due at the end of week 8. Please compile all the materials into one document. Each assessment should be included with your responses noted, followed by its reflection assignment and then the reference sheet. This order will occur 10 times for all 10 self-assessments. You will be penalized for lack of organization in this manner. This portfolio is worth 100 points.
Self-Assessment Portfolio
This assignment asks you to reflect upon your own interpersonal communication skills and evaluate your effectiveness as a communicator in interpersonal situations. There are a variety of self-assessments to choose from and the documents containing these assessments are in a folder on the course CelticOnline page. Choose 10 assessments to complete and make sure to complete the assessment first before reading more about what the assessment attempts to measure. Try to choose a variety of assessments to obtain a well-rounded understanding of your interpersonal communication skills.
After completing the assess.
Self-Assessment for Administrators ofChild Care Programs.docxtcarolyn
Self-Assessment
for Administrators of
Child Care Programs
NCSU Directors man. 12/7/01 10:35 AM Page 1
Self-assessment for
Administrators of
Child Care Programs
Achild care program director must manage manythings at once and still be able to prioritize all tasks
in a day’s time. While remaining calm and collected, the
child care director must also be aware that changes may
affect the staff and the enrolled families. Whether the
director directs a small family child care home business or
a large center, the skills are basically the same. The size
and number affected just may differ.
Day-to-day management is important. But you also need a
strong personal philosophy about children and families, a
long range plan, and set of defined goals developed along
with staff and families.
If you are interested in learning more about yourself and
the skills needed to be an excellent program administrator,
then please work through this self-assessment.
Child Care Director’s and
Administrator’s Self-assessment
North Carolina Institute for Early Childhood
Professional Development
Name ________________________________________
Current Position _______________________________
I feel my personal strengths are:
To be a more effective child care administrator,
I think I need to improve:
My career goals are:
1
NCSU Directors man. 12/7/01 10:35 AM Page 2
Self-Assessment
There are 76 items covering 11 different competency
areas in this self-assessment. For each item, think about
your abilities and skills. Then give yourself an honest
rating between one and five.
5 = I have mastered this area and could teach others.
4 = I am strong in this area but could improve.
3 = I am average in this area.
2 = I am below average in this area and could learn more
êêêabout this.
1 = I really need help with this to be more effective.
Educational Knowledge and Skills
__ 1. I understand developmentally appropriate practices
and assure that they are used in every aspect of the
program.
__ 2. I understand the particular needs and characteristics
of children at each stage of development (i.e., infan-
cy, toddlers, etc.).
__ 3. I understand how important theories (such as those
by Piaget, Erickson, & Vygotsky) can be in guiding
practice in the classroom.
__ 4. I make special adaptations to include children with
special needs in the educational program.
__ 5. I assure that staff serve on IEP teams and incorporate
appropriate activities from the IEP in the classroom.
__ 6. I know the warning signs of abuse and neglect and
know how to make appropriate referrals to
supportive services.
___ Total Educational Knowledge and Skills
Organizational Skills
__ 1.I understand the legal standing and status of the
program, its history, philosophy, & goals.
__ 2. The mission of the program is based on parental
advice and needs.
__ 3. My work with the Program Advisory Board and
other advisory groups is productive.
__ 4. I use effective short-term p.
Self Reflection PaperAt the end of the semester, students are re.docxtcarolyn
Self Reflection Paper
At the end of the semester, students are required to write a 5 to 6-page Self Reflection Paper (Times New Roman font size: 12, double-spaced) in the APA style, of what they have taken away from this class. The Self Reflection Paper is somewhat like a process of analyzing, reviewing, summarizing and also questioning the experiences gained; it is not a summary of the seven (7) Modules of the assigned reading from the text, Seven Trends in Corporate Training and Development.
Rationale for Assignment: One way we learn is from experiences—they let us absorb (through reading, hearing and feeling), they let us do the activity, and they let us interact and apply the knowledge we learn when we socialize. Dewey (1933) wrote that another way we learn is by reflecting on these experiences. When we reflect, we are linking what we had just experienced and promoting a mental framework which is more complex and interrelated. This reflection and thinking allow us to look for things that are different, having commonalities, and also those that are interrelated, hence achieving the goal of developing higher order thinking skills.
MUST USED THESE TO FOR CITATIONS
Seven Trends in Corporate Training and Development.
Dewey, J. (1933). How we think: A restatement of the relation of reflective thinking to the educative process. Boston: D.C. Health.
Rubric
Grading Rubric for Reflection/Response Paper
Grading Rubric for Reflection/Response Paper
Criteria
Ratings
Pts
This criterion is linked to a Learning OutcomeQuality of Information
1.5 pts
Good understanding in the depth and breadth of the subject matter fully and all related concepts. Quality of work suggests personal reflection. Work is of exceptional quality.
1.0 pts
Some understanding of the key concepts and draws valid inferences. Articulately reflects some ideas, opinion, and alternate approaches.
0.5 pts
Understands basic key concepts but is unable to draw inferences. Information presented has some errors.
0.0 pts
Misunderstands key concepts. Significant errors in content, interpretation of the material. Reflection not relevant to material.
1.5 pts
This criterion is linked to a Learning OutcomeCritical Thinking
1.5 pts
Enhances the critical thinking process consistently through reflection in responses.
1.0 pts
Critical thinking & reflection are sometimes demonstrated in responses.
0.5 pts
Responds to some questions but does not engage in reflection.
0.0 pts
Does not respond to posted questions.
1.5 pts
This criterion is linked to a Learning OutcomeConnection to Outside Experiences
1.0 pts
In-depth synthesis of thoughtfully selected aspects of experiences related to the topic. Makes clear connections between what is learned from outside experiences and the topic.
0.7 pts
Goes into some detail explaining some specific ideas or issues from outside experiences related to the topic. Makes general connections between what is learned from outside experiences and the topic.
0.3 pts
I.
Select one of the following modern management authors Warren Be.docxtcarolyn
Select one of the following modern management authors:
Warren Bennis
Douglas McGregor
Tom Peters
Jim Collins
Harold Geneen
Ken Blanchard
Michael Porter
Michael Hammer
John Kotter
Peter Senge
Write a three-page paper on the author you selected and answer the following questions.
Use the MLA method to cite your sources for your paper.
1. What were the most significant contributions to management theory made by the author you selected?
2. Which aspects of their theories do you think are still relevant in today’s business environmen?
3. Which aspect of their theories do you doubt are still relevant in today’s business environment?
4. If you were going to perform additional research on their theories, which aspects of their theories would, you research. Why?
.
Select one of the following individualsTed BundyAil.docxtcarolyn
Select
one of the following individuals:
Ted Bundy
Aileen Wuornos
Charles Manson
See instructor for permission for any individual not listed
Write
a 700- to 1,050-word case study about the individual you selected.
Include
or
address
the following in your case study:
A brief summary of the selected individual's childhood history, as well as a brief summary of the crimes they committed
Score the ACES based on what you can learn about the individual's history. Based on the ACES results, identify the risk factors that may have contributed to delinquent behaviors exhibited by your chosen individual.
Identify any other extrafamilial and family factors you think may have contributed to the risk that were not reflected in the ACES score.
List any protective factors that may have helped to reduce the risk.
Include at least 2 peer-reviewed resources to support your findings.
.
Select and complete one of the following assignment option.docxtcarolyn
Select
and
complete
one of the following assignment options to explain the formative influence of mass media on American culture.
Write
a 350- to 700-word summary in which you answer the following questions:
What were the major developments in the evolution of mass media during the last century?
How did each development influence American culture?
What is meant by the term
media convergence
, and how has it affected everyday life?
APA guidlines
.
Select one of the cases on civil liberties that interests you..docxtcarolyn
Select
one of the cases on civil liberties that interests you. Provide an analysis that addresses the following:
The civil liberty that is addressed in the case, including the text of the amendment from the
Bill of Rights
An explanation of the Supreme Court's involvement, including the following:
The importance of the ruling (why it is significant)
How the case moved through the lower courts to eventually be heard by the Supreme Court
The powers granted to the Supreme Court by the constitution that allowed them to rule on the case
Format
your assignment as one of the following:
18- to 20-slide presentation with detailed speaker notes
875-word paper
Include
citations for all unoriginal ideas, facts, or definitions in an APA-formatted reference list.
.
Select an organization (Gwinnett County Sheriffs Office) with.docxtcarolyn
Select
an
organization (Gwinnett County Sheriff's Office)
with which you are familiar and
obtain faculty approval for your choice. Send your instructor a message from the Message tab.
Write
a 1,400- to 1,750-word paper that includes the following:
The organizational overview.
Prioritized assessment of the strengths, weaknesses, threats and vulnerabilities of your selected organization's security system(s), including facilities, people, information systems, and other appropriate assets.
The influence of crime and criminology in your assessment, as well as applicable national and global issues.
Incorporate the
SWOT matrix
into your assignment, along with supporting narrative. Address both tabs of the attached template, SWOT and THREAT.
TurnItIn Report
.
Select a psychological disorder and a local organization that prov.docxtcarolyn
Select
a psychological disorder and a local organization that provides mental health services. Obtain faculty approval of your selected disorder before beginning this assignment.
Research
the organization's website or speak to someone in the organization.
Write
a 700- to 1,050-word paper in which you examine your selected psychological disorder in the context of the chosen organization's goals. Include the following in your paper:
Identify multiple cultures the organization serves.
Identify symptoms of your selected disorder and describe how the interpretation of the symptoms varies across cultures.
Discuss how the impact of culture affects interpretations of symptoms and recommendations of services for that organization.
Include
a minimum of three credible, peer-reviewed references.
Format
your paper consistent with APA guidelines.
.
Senior Design Report Sample
Description:
This senior design project is called SafeStride. It is designed and made for people who do not have the ability to walk or need help walking. Many people around the world, and especially in the United States, who do not have the ability to walk without using cranes and crutches. However , there are many who use these tools incorrectly, therefore causing more harm on themselves rather than heeling themselves. So SDSU Electrical Engineering seniors came up with an idea of SafeStride in an effort to improve walking aids. The seniors came up with an idea of a cane that assists better in walking than the crutches and canes we see today. With the development of software technology and programming, students were able to make this cane send and receives data from a program, which then used by therapists and medical professionals to check if the cane is used appropriately by the person or not.
Devices:
There are many devices used in this project. For instance, one device is the Bluetooth RN42 chip. This device is coordinated to send information to a gadget where experts play out their investigation. More so, a lithium-ion battery that has energy which controls the gadgets found in the stick. At the base of the stick, there is a cell that checks the weight applied on the stick by the client. Also, there is a 18560 battery which is utilized to control up the stick's hardware through the charging of the battery. To get this stick working, sensors were used to measure metrics and use signals to send it to microcontrollers, and after they are sent by wireless to the computer.
Cost:
The project costed the students $643.43, $79.94 for the power components, $59.85 for the IMU, $120.54 for the Bluetooth Module, $125.70 for other components, and $151.85 for the materials of the cane.
Purpose of Assignment
This activity helps students recognize the significant role accounting plays in providing financial information to management for decision making through the evaluation of financial statements. This experiential assignment requires students to use ratios to evaluate and analyze a company’s liquidity, solvency, and profitability.
Two-Rivers Inc. (TRI) manufactures a variety of consumer products. The company's founders have run the company for thirty years and are now interested in retiring. Consequently, they are seeking a purchaser, and a group of investors is looking into the acquisition of TRI. To evaluate its financial stability, TRI was requested to provide its latest financial statements and selected financial ratios. Summary information provided by TRI is presented below.
Required:
a. Calculate the select financial ratios for the fiscal year Year 2. (use MS word or excel but excel is more recommended)
b. Interpret what each of these financial ratios means in terms of TRI's financial stability and operating efficiency.
500 words
Click the Assignment Files tab to submit your assignment.
Abstract :
K.
Seminar in Public Human Resources Administration Questions & Key Te.docxtcarolyn
Seminar in Public Human Resources Administration: Questions & Key Terms [Day One]
Critical Thinking Questions
1. Identify and describe the four public personnel management functions (PADS).
2. What are the four competing values that have traditionally affected the allocation of public jobs? Which three nongovernment values that have emerged recently conflict with them?
3. What is a personnel system?
4. What are the key programs that are impacting public personnel systems? Give an example of each.
5. Identify and describe the four traditional competing public personnel systems. What are the two emergent antigovernment personnel systems that have recently been added to them?
6. What does each of these three groups (elected and appointed officials, managers and supervisors, and HR directors and specialists) contribute to public personnel management?
7. What are the six stages in the development of the role of the public HR manager? What different expectations have people had for them in each stage?
8. What competencies do HR managers need, and where can they get them?
Key Terms: Please define and give one example
1. Civil Service Reform Act of (1978)
2. civil service (merit) system
3. collective bargaining
4. decentralized government
5. equal employment opportunity systems
6. faith-based organizations (FBOs)
7. franchise agreements
8. human resource management (HRM)
9. nongovernmental organizations (NGOs)
10. nonstandard work arrangements (NSWA)
11. Office of Personnel Management (OPM)
12. partnerships
13. Pendleton Act (1883)
14. political patronage system
15. privatization
16. contingent workers
17. exempt appointments
18. professional associations
Doing Public HRM in the USA
1
1
Leadership vs Management of Public HMR
What is leadership?
What is management?
How does leadership and management of HMR compliment each other
and how do they conflict with each other?
2
All
Solution
s are tomorrow’s problem,
Redefine the problem as a challenge,
then look for opportunities.
3
Problems that impact Public HRM in the USA
How many public employees are there?
Is it really cheaper to use third-party government and contingent workers than a public worker?
How many others share in the responsibilities with personnel managers and their technical specialist in the supervision of HRM?
How do they work in practice?
How do these shared HRM roles and functions translate into structures and administrative in a given organization?
How do the evolving values and systems affect the roles and competencies of public HRM?
4
Myths and Realities of Public Employment
All federal employees symbolize government bureaucracy!
In reality they only constitute about 13 percent of all public workers.
The primary federal functions are national defense, postal service, and financial management.
The primary state and local functions are education, police protection, highways, corrections, welfare, and utilities.
Education comprising mo.
Seminar in Strategic-3 Management-V3BAjay K. Garg604-648-4.docxtcarolyn
Seminar in Strategic-3 Management-V3B
Ajay K. Garg
604-648-4495
[email protected]
Executive Summary
An executive summary is a brief section at the beginning of a long report, article, recommendation, or proposal that summarizes the document.
It is not background and not an introduction.
People who read only the executive summary should get the essence of the document without fine details.
The executive summary is concise, typically one to two pages long, and presents the main points in a formal tone.
For example, a business plan for an external audience includes financial information and details on the size and scale of a company.
Startups seeking funding and investors treat the executive summary as a way to get the reader’s attention by highlighting specific financial requirements and how it impacts the business strategy.
Summarize the information you’re presenting in a manner that keeps the reader engaged and motivated to continue reading.
Introduction
Introduction:
The opening statement, paragraph, or section should clearly state the document’s purpose and the content to follow.
Deciding on how to use this section comes down to the desired outcome for the reader or audience.
They want to immediately find value in the information you present, so the details included in the introduction should grab and hold the reader’s attention.
Company Information
Company Information:
When writing an executive summary for an external audience, include your company name, a description of your mission or purpose, contact information, location, and the size and scale of your operations.
In some cases, the summary introduces the founders, investors, and corporate leadership.
It might include background information of each that outlines previous industry or startup experience, or historical context on the current state of the company.
When used in a presentation or research report, introduce the team presenting or responsible for the report’s findings.
Products and Services
Products and Services:
The executive summary is the place to highlight the problem you solve or the need you fulfill.
For a report, this is where you might highlight what you researched and what the reader should know about your findings.
For marketing plans or product launch presentations, tell the reader why your service or product is relevant at this particular moment in time.
Market Analysis
Market Analysis:
The executive summary of a business plan might profile the target customer and explain the market opportunity for a product or service.
Consider answering questions like: Is there a five year plan for this market?
How do you anticipate growing the customer base and improving market share?
What stands out from your research about your customers that the reader should know before you summarize the rest of the business?
Competition Analysis
Competition Analysis:
This section should include answers to the following questions:
Wh.
Semi-literate children in a remote village were given access to a co.docxtcarolyn
Semi-literate children in a remote village were given access to a computer and taught themselves molecular biology.
Discuss in 500 words what this says about governments responsibility to break the
digital divide
. Include at least one quote enclosed in quotation marks and cited in-line.
.
Semester Spring 2020Course Code PHYS218Course Title.docxtcarolyn
Semester: Spring 2020
Course Code: PHYS218
Course Title: Modern Mechanics
Experiment #: TAP 3
Experiment Title: VARIABLE g PENDULUM
Date: ……………………….. Lab#................................
Section: ……………………….
Student Name
Student ID
Feedback/Comments:
Grade: …….. /100
1. Introduction
This experiment explores the dependence of the period of a simple pendulum on the acceleration due to gravity. A simple rigid pendulum consists of a 35-cm long lightweight (28 g) aluminum tube with a 150-g mass at the end, mounted on a Rotary Motion Sensor. The pendulum is constrained to oscillate in a plane tilted at an angle from the vertical. This effectively reduces the acceleration due to gravity because the restoring force is decreased.
2. Objectives
· Measure the effective length of variable-g pendulum.
· Measure the period of a variable-g pendulum for different values of the tilt angle and verify the dependence of the function T versus .
· Measure moment of inertia
3. Experimental setup:
· Large rod base
· 45 cm stainless steel rod
· Angle indicator
· Rotary motion sensor
· Pendulum accessories
· Air link PASPORT interface
4. Theory
The period of a simple pendulum is given by:
(1)
Where is the acceleration due to gravity and the approximation becomes exact as the amplitude of the oscillation goes to zero. We will limit to angles less than 10° (0.17 rad) where assuming the equality in equation 1 holds produces an error of a fraction of a percent. Here it is understood that is a constant acceleration that acts in the plane of oscillation.
The pendulum we use is actually a physical pendulum (not a point mass) so equation 1 is replaced by the rotational analog:
(2)
where I is the moment of inertia of the system about the fixed axis, m is the mass of the brass masses (150 g) plus the rod (26 g), and r is the distance from the axis to the center of mass of the rod plus masses (~31 cm). Note that I, m, & r are all constant and that I/mr must have the units of length so we may write:
(3)
where is the effective length of a simple pendulum that would behave the same as our physical pendulum. We may then re-write equation 2 in the form of equation 1:
(4)
We will determine by measuring the period when . Then we have:
(5)
In this experiment, the acceleration will be varied by tipping the plane of oscillation of the pendulum by an angle of θ from the vertical (figure 1). The component of g that is in the plane of oscillation is where:
(6)
Figure 1: Components of g
Note that the component of g perpendicular to the plane of oscillation, , is cancelled by forces in the rod since no motion is allowed in this direction. Putting it all together gives:
(7)
Finally, combining equation (4) and (6) we have:
(8)
5. Pre-lab Preparation
Read section 11.2 (page 422). Also read the slides posted on Moodle corresponding to chapter 11.
6. Experimental Procedure
a) Adjust the an initial angle of 0° (figure.
Semester Paper • The paper must be a minimum eight page (e.docxtcarolyn
Semester Paper
• The paper must be a minimum eight page (excluding the cover and reference pages)
double spaced paper in APA format (consult a model which is on Blackboard above
where the videos for this class are located).
• This paper should be over a peace and justice topic the student has a genuine interest in
(and be related in one or more ways with the organization one has selected).
• The student’s identification and initial contact with a peace group or organization must be
an important part of this paper around which selected peace study theory, concepts and
ideas must revolve (consult Louisville Peace Web on Blackboard above where the videos
for this class are located). If a student in this class does not live in or close to the
Louisville area, and a peace and justice organization of interest is in their area, it is best
that that organization be the student’s focus.
• The peace study group or organization with which one will work must be documented in
an appendix to the paper, as well as in the references page(s).
• Students must be given written email approval for the paper topic by the instructor at
least one calendar month prior to the due date.
• The student will provide a purpose for the topic, a tentative title, and, two sources with
one being a peer review journal source in order for approval to be granted.
NOTE: Since the capstone course (PEAC 550) requires a longer paper and hours of work
with a peace and justice organization, this assignment in PEAC 325 is designed to make
the transition to the capstone class considerably easier. As such this paper should not
only focus on an instructor approved topic of genuine interest to the student, but also
requires the documentation of the initial stage of identification, (in-person) contact and
acceptance for later work with a peace and justice organization in the Louisville area (or
the area nearest where the student is located if the student does not reside in the
Louisville area). Additionally, the peace and justice organization name, mission and
goal(s) must be integrated into the paper in an appropriate place.
NUR204: Week 9 Assignment Page 1
`
Assignment: Change Paper
Assignment Overview
In this assignment, you will assess a current semi-direct or indirect nursing situation that is in need
of change. Observe a healthcare environment, focusing on areas of the nursing process that are
inefficient, unsafe, or problematic in nature. Diagnose the problem and choose a nursing change
theory that suits the change(s) you want to make. Propose a detailed plan based on your chosen
change theory, explaining how to implement change. Develop criteria to evaluate the effectiveness
of the plan and include a timeline for your change proposal. Finally, reflect on how your change
affects the nursing profession.
Assignment Details:
Perform the following tasks:
Complete the reading assignment and.
Selling to the Government Best Prospects for Small Entreprene.docxtcarolyn
Selling to the Government : Best Prospects for Small Entrepreneurial Firms Page 2
International Management
Summer B
Professor J. Haar
Selling to the Government:
Best Prospects for Small Entrepreneurial Firms
Prepared By:
Andrew Hussey
Cecilia Jimenez
Juan Diego Membreño
Table of Contents
3Introduction - Why Sell to the Government?
4Department of Defense (DoD) - Brief Information
5Laws, Rules, Restrictions/ Limitations
7Confidentiality and Security
8Small Businesses Programs
12Contracting Methods & Bidding Procedures
15Contracts
16General Services Administration - GSA
17Advantages and Disadvantages of Selling to the Government
18Effects of Political Change
19Best Prospects for Small Businesses Entrepreneurs – By Industry
21Other Government Trends
23CASES AND SUCCESS STORIES:
24Rose Wang &Binary Consulting Inc.
24Lurita Doan & New Technologies Management Inc.
25Turkish Firms Using DoD Procurement Programs
25Bavarian Nordic – Denmark, Biopharmaceutical Company
26Steps to Consider
28Difficulties
30Foreign Firms and US Government Contracts
31Strategies and Final Recommendations
32Conclusion
34REFERENCES
38APPENDIX
Selling to the Government: Best Prospects for Small Entrepreneurial Firms
Introduction - Why Sell to the Government?
Selling to the United States government is a multi-billion dollar market – per year. The size of this market cannot be given a specific monetary value, due to the fact that every year, the U.S. government spends more money than it did in the previous year. Trends are showing that government spending increases every year sometimes by as much as ten to twenty percent. Back in the mid-1980s, selling to the government was roughly a $30 billion per year market (Black 1989). Since then, government spending has increased more than ten fold. This is especially apparent in the defense segment of the government. The United States government will not hesitate to spend whatever it needs to satisfy the wants of its defense, regardless of how much it stands to lose or gain.
With a market this big, there is no end to the opportunities that exist for the small business man or woman. This paper will focus on the opportunities that exist for disadvantaged small entrepreneurial firms who would like to sell to the government and touch on what would be required for such a firm to do so. The thought of having the government as a consumer of these small disadvantaged businesses seems like an awkward situation, but it provides for much of the growth of these small firms, both domestic and foreign.
[See Definition in Appendix for Small/Disadvantaged/Minority Firm]
Department of Defense (DoD) - Brief Information
The United States Department of Defense, created in 1949, is the executive department of the government that watches over everything involving or relating to national security and the military (DoD “About DoD” 2007). Its headquarters is the Pentagon, located in Arlington County, Virginia. The DoD has more.
Select a legal case from the following list or another case relate.docxtcarolyn
Select
a legal case from the following list or another case related to psychological assessment
Legislation
Americans with Disabilities Act of 1990
Civil Rights Act of 1964 (amended in1991), also known as the Equal Opportunity Employment Act
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Write
a 1,500- to 1,750-word paper discussing:
The background of your selected case and the legal implications of the decision
An analysis of the biases related to the assessments in the case
The ethical implications for diverse populations in relationship to the case
The role of norming in creating bias
.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Francesca Gottschalk - How can education support child empowerment.pptx
Seminar1240 www.thelancet.com Vol 387 March 19, 2016.docx
1. Seminar
1240 www.thelancet.com Vol 387 March 19, 2016
Attention defi cit hyperactivity disorder
Anita Thapar, Miriam Cooper
Attention defi cit hyperactivity disorder (ADHD) is a
childhood-onset neurodevelopmental disorder with a prevalence
of 1·4–3·0%. It is more common in boys than girls. Comorbidity
with childhood-onset neurodevelopmental
disorders and psychiatric disorders is substantial. ADHD is
highly heritable and multifactorial; multiple genes and
non-inherited factors contribute to the disorder. Prenatal and
perinatal factors have been implicated as risks, but
defi nite causes remain unknown. Most guidelines recommend a
stepwise approach to treatment, beginning with
non-drug interventions and then moving to pharmacological
treatment in those most severely aff ected. Randomised
controlled trials show short-term benefi ts of stimulant
medication and atomoxetine. Meta-analyses of blinded trials
of non-drug treatments have not yet proven the effi cacy of
such interventions. Longitudinal studies of ADHD show
heightened risk of multiple mental health and social diffi
culties as well as premature mortality in adult life.
Introduction
Attention defi cit hyperactivity disorder (ADHD) is a
childhood-onset neurodevelopmental disorder char ac-
terised by developmentally inappropriate and impairing
inattention, motor hyperactivity, and impulsivity, with
diffi culties often continuing into adulthood. In this
2. Seminar, we aim to update and inform early career
clinicians on issues relevant to clinical practice and
discuss some controversies and misunderstandings.
Defi nitions of ADHD
ADHD is a diagnostic category in the American
Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders 4th edition (DSM-IV)1 and
the more recent DSM-5.2 The broadly equivalent
diagnosis used predominantly in Europe is hyperkinetic
disorder, which is defi ned in WHO’s International
Classifi cation of Diseases (10th edition; ICD-10).3 This
defi nition captures a more severely aff ected group of
individuals, since reported prevalence of hyperkinetic
disorder is lower than that of DSM-IV ADHD, even
within the same population.4 Key diagnostic criteria are
listed in the panel. DSM-5 has longer symptom
descriptors than those used in DSM-IV; these descriptors
also capture how symptoms can manifest in older
adolescents and adults. DSM-IV distinguished between
inattentive, hyperactive–impulsive, and combined sub-
types of ADHD; a diagnosis of the combined subtype
required the presence of symptoms across the domains
of inattention and hyperactivity–impulsivity. However,
ADHD subtypes are not stable across time,5 and DSM-5
has de-emphasised their distinctions. ICD-10 does not
distinguish subtypes; symptoms need to be present from
the three separate domains of inattention, hyperactivity,
and impulsivity for a diagnosis of hyperkinetic disorder.
The diagnosis of ADHD or hyperkinetic disorder also
requires the presence of symptoms across more than
one setting (eg, home and school) and requires that the
symptoms needed for diagnosis result in impairment,
for example in academic, social, or occupational
3. functioning. Onset must be early, although DSM-5 has
changed the age of onset from before age 7 years (ICD-10
and DSM-IV) to before age 12 years.
Like all complex medical and psychiatric disorders,
ADHD shows marked heterogeneity at clinical,
aetiological, and pathophysiological levels. Individuals
with a diagnosis of ADHD diff er from each other in
terms of their core symptom combinations, level of
impairment and comorbidities, as well as on other
background individual, family, and social factors.
For clinical purposes, defi ning ADHD categorically is
useful given that clinical decisions tend to be categorical
in nature—eg, whether to refer to specialist services or to
treat. However, like many medical disorders (such as
hypertension and diabetes), in terms of causes and
outcomes, ADHD can be viewed as a continuously
distributed risk dimension. In common with other
continuously distributed phenotypes (eg, blood pressure),
it could be argued that there is a lack of an objective
cut-point that defi nes the diagnostic threshold.
Indeed, individuals with subthreshold symptoms are at
heightened risk of adverse outcomes6 (as is seen in
hypertension). However, ultimately, categorical decisions
on resource allocation and treatment have to be made,
Lancet 2016; 387: 1240–50
Published Online
September 17, 2015
http://dx.doi.org/10.1016/
S0140-6736(15)00238-X
Child & Adolescent Psychiatry
4. Section, Institute of
Psychological Medicine and
Clinical Neurosciences, and
MRC Centre for
Neuropsychiatric Genetics and
Genomics, Cardiff University
School of Medicine, Cardiff , UK
(Prof A Thapar FRPsych,
M Cooper MRCPsych)
Correspondence to:
Prof Anita Thapar, Institute of
Psychological Medicine and
Clinical Neurosciences, Cardiff
University School of Medicine,
Hadyn Ellis Building, Maindy
Road, Cathays, Cardiff
CF24 4HQ, UK
[email protected] .ac.uk
Search strategy and selection criteria
To identify studies for this Seminar, we searched PubMed for
papers published between Jan 1, 2010, and March 31, 2015,
using the search terms “ADHD”, “aetiology”, “epidemiology”,
“prevalence”, “gender”, “time trends”, “prescribing”, “genetic”,
“prenatal”, “psychosocial”, “toxins”, “institutional rearing”,
“longitudinal”, “prognosis”, “animal model”, “biological
5. pathway”, “cognition”, “neuroimaging”, “comorbidity”,
“neuropsychological”, “medication”, “stimulants”,
“behavioural interventions”, “nonpharmacological
interventions”, “diet”, and “outcomes”. Only articles published
in English were included. Key recent reviews and book
chapters were also examined. To reduce the number of papers
cited, the most up-to-date review papers and meta-analyses
were used where possible. We selected papers according to our
judgment of the quality of the study or review paper, the
relevance to controversial or commonly misunderstood
issues, and whether fi ndings had clinical relevance.
We included older papers that we judged to be important.
http://crossmark.crossref.org/dialog/?doi=10.1016/S0140-
6736(15)00238-X&domain=pdf
Seminar
www.thelancet.com Vol 387 March 19, 2016 1241
and ICD-defi ned or DSM-defi ned diagnosis provides a
reliable way of balancing the risks and benefi ts of giving
an individual a diagnostic label and providing treatments
that are not free of adverse eff ects. A further challenge,
which occurs in all psychiatric disorders and some
neurological disorders (eg, migraine), comes from the
diagnosis being based on reported symptoms alone;
there are no biological tests. This diffi culty means that
even with clear-cut diagnostic criteria, there is potential
risk of overdiagnosis and underdiagnosis, which
underscores the importance of careful and rigorous
expert assessment.7 Concerns about underdiagnosis and
overdiagnosis are not restricted to ADHD or psychiatric
disorders.8
6. Epidemiology
In the general population, the estimated prevalence of
ADHD in children is 3·4% (95% CI 2·6–4·5) according
to the most recent meta-analysis,9 with lower rates of
around 1·4% reported for hyperkinetic disorder from
European studies.10 International comparisons show
that prevalence does not vary by geographical location
but is aff ected by heterogeneity in assessment methods
(eg, use of an additional informant to the parent or
carer) and diagnostic conventions (eg, ICD vs DSM).11
Notably, there is a marked under-representation of
studies on ADHD from low-income and middle-income
countries.
One common assumption is that ADHD must be a
modern occurrence. However, a case series of children
presenting with the characteristic clinical features was
published by the British paediatrician Sir George Still in
The Lancet in 1902,12 and there are descriptions that
pre-date this publication by several centuries. Time
trends studies of non-referred population cohorts in the
late 20th and early 21st centuries show no evidence of a
rise in rates of ADHD symptoms or diagnosis across
time.13,14 However, there has been a very marked rise in
the number of prescriptions issued for ADHD pharma-
cological treatment across high-income countries in the
past decade.15–17 Rises in clinic incidence and treatment
could simply indicate increased parent and teacher
awareness of ADHD or changes in the impact of
symptoms on children’s functioning, or both.18,19 Never-
theless, European studies have repeatedly reported that
despite the rise in ADHD treatment, the admin is trative
prevalence is lower than the population fi gure,
highlighting that in these countries there is still
underdiagnosis.17,20,21 However, in the USA, similar types
of studies show geographical variation in patterns
7. of underdiagnosis and overdiagnosis or in ADHD
medication prescribing.22,23 Such fi ndings highlight that
there is the potential for misdiagnosis and inappropriate
use of pharmacological interventions if safeguards are
not in place. These safeguards include ensuring full,
good-quality clinical assessments are undertaken, even
though these require time, and adherence to national
and international treatment guidelines. However, there
is no evidence of rising population rates of ADHD
explained by social change, contrary to the opinion of
some people.
An excess of aff ected male individuals is a strongly
consistent epidemiological fi nding, although the
male:female ratio of 3–4:1 recorded in epidemiological
samples is increased in clinic populations to around 7–8:1,
suggesting referral bias in relation to female patients with
ADHD.24 The same male preponderance is seen for other
neurodevelopmental disorders such as autism spectrum
disorder, intellectual disability (intelligence quotient [IQ ]
<70), and communication disorders.25
The natural history of ADHD is best examined in
prospective longitudinal studies. As is typical of
neurodevelopmental disorders, the core defi ning features
of ADHD tend to decline with age, although inattentive
features are more likely to persist. However, in line with its
heterogeneous clinical presentation, the develop mental
trajectories of ADHD are highly variable. Although
around 65% of patients continue to meet full criteria or
have achieved only partial remission by adulthood, some
patients do achieve full remission.26 Good-quality, large
epidemiological studies of the prevalence of ADHD in
adulthood are lacking, but one meta-analysis of adult
ADHD yielded a pooled prevalence of 2·5% (95% CI
8. 2·1–3·1).27 However, there are still uncertainties as to what
constitutes the best way of defi ning ADHD (or indeed any
Panel: Key diagnostic symptoms of attention defi cit
hyperactivity disorder2
Inattentive symptoms
• Does not give close attention to details or makes careless
mistakes
• Has diffi culty sustaining attention on tasks or play activities
• Does not seem to listen when directly spoken to
• Does not follow through on instructions and does not
fi nish schoolwork, chores, or duties in the workplace
• Has trouble organising tasks or activities
• Avoids, dislikes, or is reluctant to do tasks that need
sustained mental eff ort
• Loses things needed for tasks or activities
• Easily distracted
• Forgetful in daily activities
Hyperactivity or impulsivity symptoms
• Fidgets with or taps hands or feet, or squirms in seat
• Leaves seat in situations when staying seated is expected
• Runs about or climbs when not appropriate (may present
as feelings of restlessness in adolescents or adults)
• Unable to play or undertake leisure activities quietly
• “On the go”, acting as if “driven by a motor”
• Talks excessively
• Blurts out answers before a question has been fi nished
• Has diffi culty waiting his or her turn
• Interrupts or intrudes on others
9. Seminar
1242 www.thelancet.com Vol 387 March 19, 2016
neurodevelopmental disorder) in adulthood. DSM-5
explicitly allows for symptom decline and requires a
reduced number of symptoms for diagnosis of adult
ADHD.2 In clinical settings, diagnosis of ADHD in adults
who did not present in childhood requires some caution
in the absence of documented information because of the
diffi culty for young adults and those who know them to
date symptom onset retrospectively.28 Objective records
(eg, school reports) could help in this regard. Despite
these caveats, there is certainly suffi cient evidence to
conclude that ADHD is not simply a problem that most
children grow out of. However, transitioning from child to
adult mental health clinics is diffi cult because of a scarcity
of adult services.29
Early comorbidity
ADHD shows high concurrent comorbidity with other
neurodevelopmental disorders—namely, autism spec-
trum disorder, communication and specifi c learning or
motor disorders (eg, reading disability, developmental
coordination disorder), intellectual disability, and tic
disorders.30–32 Unsurprisingly, rates of comorbidity are
higher in individuals who are clinically referred than in
those who are not referred.33 ADHD also shows high
concurrent comorbidity with behavioural problems—
namely, oppositional defi ant and conduct disorders.31,34
Conduct disorder is a risk marker for greater
neurocognitive impairment and worse prognosis in
children with ADHD.35,36 This subgroup of children
with hyperkinetic conduct disorder is distinguished in
10. ICD-10 but not in DSM-5.
Risk factors
Overview
As for all complex disorders, no single risk factor is either
necessary or suffi cient to explain ADHD—many genetic
and non-genetic (or environmental) factors contribute to
risk, and the pattern of inheritance is multifactorial for
most aff ected individuals.
Genetics
ADHD is a familial disorder. Its relative risk is about
5–9 in fi rst-degree relatives of probands with ADHD.37
Many twin studies of ADHD from diff erent countries
have consistently yielded very high heritability estimates
of about 76%, a magnitude similar to that reported for
schizophrenia and autism.38
The genetic architecture of ADHD is similar to other
neuropsychiatric disorders such as schizophrenia. Several
diff erent classes of genomic variants have been identifi ed
to be associated with ADHD risk.39 These variants include
common (defi ned as >5% population frequency) DNA
sequence variants called single nucleotide polymorphisms
(SNPs), but associations have only been reported when
thousands of SNPs are combined into a composite
genetic risk score.40 Subtle chromosomal mutations,
such as rare (defi ned as <1% frequency) deletions and
duplications called copy number variants (CNVs), are also
associated with ADHD risk.41 These have larger eff ect
sizes but are uncommon.
Before whole-genome investigations, specifi c single
dopaminergic, serotonergic, and noradrenergic candidate
genes were signifi cantly associated with ADHD status
11. in meta-analyses.42,43 However, in the present era of
whole-genome investigation, psychiatric candidate gene
studies of DNA variants in single genes are viewed with
caution because of the potential for false positives.44
ADHD-associated genomic variants are non-specifi c;
composite genetic risk scores show signifi cant overlap
with those contributing to schizophrenia and mood
disorders.45,46 ADHD-associated CNVs also show overlap
with ones associated with schizophrenia, autism, and
intellectual disability.41,47 Although testing for rare CNVs
is now recommended for individuals with intellectual
disability, this is not the case for ADHD. Ascertaining
causality requires further and diff erent types of
investigation, as reviewed elsewhere.39
Although most cases of ADHD are multifactorial in
origin, there are several known, rare genetic syndromes
(such as fragile X syndrome, tuberous sclerosis, 22q11
microdeletion, and Williams syndrome) characterised by
high rates of ADHD and ADHD-like features. These
syndromes are also associated with high risk of other
disorders, such as autism (especially in fragile
X syndrome and tuberous sclerosis) and schizophrenia
(22q11 microdeletion syndrome). In typical clinic
populations with ADHD, there is no evidence that
routine screening for these genetic syndromes is
warranted in the absence of intellectual disability.48
Environment and gene–environment interplay
Environmental factors are also known to be important in
ADHD. Because evidence for modifi able causes can
aff ect clinical decision making, public health priorities,
and clinician and patient behaviour,49 we will discuss
whether fi ndings on individual environmental risks
meet accepted standards for inferring causation.50
12. Observational case-control and epidemiological studies
show that exposures to a range of prenatal and perinatal
factors, environmental toxins, dietary factors, and psycho-
social factors are all associated with ADHD.38 If these
associations are causal, it means manipulation of the risk
factor can alter the outcome. However, association does
not mean causation, because exposures to risks are not
randomly allocated and can be aff ected by unmeasured
confounders, selection factors, and reverse causation,
whereby the phenotype infl uences the environmental
exposure. Evidence for environmental causation must be
interpreted with these caveats in mind.
Prenatal and perinatal factors reported to be associated
with ADHD are low birthweight and prematurity,51 and
in-utero exposure to maternal stress, cigarette smoking,
alcohol, prescribed drugs (eg, paracetamol), and illicit
substances.38,52,53 In relation to prenatal smoking and
Seminar
www.thelancet.com Vol 387 March 19, 2016 1243
stress, quasi-experimental designs suggest that most or
all of the association with off spring ADHD, unlike with
off spring birthweight, is explained by unmeasured
confounding factors.54–58
Environmental toxins, specifi cally in-utero or early
childhood exposure to lead, organophosphate pesticides,
and polychlorinated biphenyls, are risk factors for
ADHD, as reviewed elsewhere.38 Nutritional defi ciencies
(eg, zinc, magnesium, and polyunsaturated fatty acids),
13. nutritional surpluses (eg, sugar and artifi cial food
colourings), and low or high IgG food have not been
shown convincingly to precede ADHD and at present
should be regarded as correlates. Eff ective treatments for
any disorder, unlike prevention, do not necessarily have
to deal with its causes or origins.
Psychosocial risks, such as low income, family
adversity, and harsh or hostile parenting, although
robustly causal for some psychiatric disorders, are also
correlates rather than proven causes of ADHD.
Longitudinal studies,59 treatment trials,60 and a study of
children adopted away at birth61 suggest that observed
negative mother–child relationships (even in unrelated
mothers) arise as a consequence of early child ADHD
symptoms (reverse causation) and improve with
treatment. However, exposure to very severe, early
social deprivation seems to be diff erent and causal.
After being adopted away in the UK, Romanian orphans
raised in institutions and exposed to extreme early
privation in the fi rst year of life showed increased rates
of ADHD-like features, cognitive diffi culties, and
quasi-autistic features that persisted into adolescence.62,63
Psychosocial context may well shape ADHD presen ta-
tions and alter developmental trajectories, outcomes,
and impairments, but surprisingly this has not been
investigated widely (fi gure 1). Irrespective of the cause
of ADHD, treatment is based on clinical features and
not assumed aetiology.
As a fi nal word on risk factors, many individuals
mistakenly assume that the actions of genes (or biology)
and environment are distinct. Potentially important
environmental risks for ADHD and its outcomes may be
brought about as a consequence of genetic propensities
(gene–environmental correlation61). The eff ect of
14. environmental factors on clinical phenotype may also
depend on genetic liability. For example, animal studies
have robustly shown that environment can alter
behaviour in diff erent ways depending on the variant of
gene carried (gene–environment interaction39). Eff ects of
gene–environment interplay are subsumed in twin
heritability estimates. Finally, there is very good evidence
that environmental exposures result in biological
changes,49 including ones involving brain structure,
function, and altered DNA methylation (epigenetics).
These fi ndings highlight that genes, environment, and
biology work together. However, in man, these issues are
complex; they will not be discussed in detail here, but
have been reviewed elsewhere.38,39,49
Pathophysiology
Biology
The biological mechanisms through which genetic and
environmental factors act and interact to alter neuro-
development in ADHD are not yet understood and there
remains no diagnostic neurobiological marker. The
validity of animal models of ADHD are limited by our
incomplete understanding of its pathophysiology in
man and the extent to how well inattention, motor
overactivity, and impulsive responses on behavioural
tasks in non-human species represent ADHD.64
However, fi ndings in animal models have suggested
involvement of dopaminergic and noradrenergic
neurotransmission (in line with the neurochemical
eff ects of ADHD medications) as well as involvement of
serotonergic neurotransmission.65
Cognition
Although there is no cognitive profi le that defi nes
ADHD, defi cits in various neuropsychological domains
have been reliably identifi ed. In terms of executive
15. functioning, the most consistent and strong associations
are seen for response inhibition, vigilance, working
memory, and planning.66 In terms of non-executive
defi cits, associations are seen with timing,67 storage
aspects of memory,68 reaction time variability,69 and
decision making.70 However, there is substantial
heterogeneity in cognitive functioning even within
single samples,71 and there is not a straightforward
association between cognitive performance and the
trajectory of clinical symptoms.72,73 There is evidence,
though, that some cognitive defi cits are improved by
methylphenidate, with a meta-analysis showing
improvements in executive and non-executive memory,
reaction time, reaction time variability, and response
inhibition.74
Figure 1: Origins and trajectories of attention defi cit
hyperactivity disorder
(ADHD)
Multiple early risk factors contributing to the development of
ADHD
Genetics Early environment
(prenatal and postnatal)
ADHD Later risk and protective factors
modifying the course
Family and social environment
Genetics
Heterogeneous
outcomes
16. Seminar
1244 www.thelancet.com Vol 387 March 19, 2016
Imaging
Functional MRI (fMRI) studies in patients with ADHD
have found abnormalities in the function of many neural
networks in response to cognitive tasks. A meta-analysis
of task-based fMRI studies identifi ed alterations in
several networks, including those related to attention
and executive function.75 In terms of brain structure, a
meta-analysis of structural MRI studies highlighted
alterations in the basal ganglia and limbic areas.76
In a meta-analysis of diff usion MRI studies investigating
white matter microstructure, alterations were reported
to be widespread, but most reliably seen in the right
anterior corona radiata, right forceps minor, bilateral
internal capsule, and left cerebellum.77 Reduced total
grey matter and altered basal ganglia volumes seem to
index familial risk for ADHD.78
The scientifi c literature is increasingly suggesting
that the pathophysiology of ADHD involves abnormal
interactions between large-scale brain networks; however,
current imaging studies do not yet have relevance to
clinical practice.79 Interpretation is complex because of
many factors, including the cross-sectional nature of
most studies. Longitudinal data regarding the trajectory
of cortical development suggest that the brain may show
maturational delay, with persistence of ADHD indexed
by progressive divergence from the normal trajectory,80
but it is not known whether this phenomenon can be
extrapolated to other metrics of structure, microstructure,
17. and function. The eff ect of pharmacological treatment is
also a consideration because there is some evidence to
suggest that it normalises macrostructure and function.81
Nonetheless, there is some evidence from longitudinal
studies of adults with childhood ADHD that grey and
white matter abnormalities persist well into adulthood.82,83
Clinical assessment
The assessment process for ADHD requires careful
clinical history taking that goes beyond asking yes or no
questions in relation to core ADHD symptoms. A missed
diagnosis has potential to jeopardise an individual’s
learning or occupational and social relationships, whereas
a misdiagnosis could lead to the use of pharmacological
treatment that is not needed. History taking should not
be reductionist—ie, exclusively focused on asking about
diagnostic items. A detailed developmental as well as
medical history and an assessment of family processes
and social circumstances (strengths as well as weaknesses)
are also required. Figure 2 summarises the key steps in
the assessment of children.
It is important to consider whether endorsed symptoms
are better explained by other diffi culties that are amenable
to intervention—eg, hearing diffi culties presenting as
inattention. However, diagnosis is based on clinical
phenotype and not generally excluded by presumed
cause. Information should be obtained from more than
one informant, including those who know the aff ected
individual best at home and at school (or college or work).
To decide which individuals need referral to a specialist
assessment service or to monitor treatment response, use
of standardised ADHD questionnaires (eg, Strength and
Diffi culties Questionnaire,84 Conners’ Parent and Teacher
Rating Scales85) are helpful, but these are not a substitute
for detailed history taking before diagnosis. Structured
18. interviews are more likely to be encountered in a research
setting, but might be valuable in a clinical context,
especially interviews that do not require extensive,
expensive training (eg, the Development and Wellbeing
Assessment).86 The use of structured interviews in a
clinical setting requires further investigation. ADHD
symptoms are commonly associated with a range of
neurobehavioural diffi culties, which could be comorbid
features of the disorder but should also be considered
as diff erential diagnoses because their treatments are
very diff erent.
Mental health symptoms, which should also be
screened for, include those of oppositional defi ant
disorder, conduct disorder, anxiety, and mood
disturbance. Developmental and learning problems
such as reading disorders, developmental coordination
disorder, and tic disorders are also common.87–89 Because
ADHD and autism spectrum disorder co-occur so
frequently,90 autistic symptomatology should be
considered. ADHD is also associated with lower IQ
or intellectual disability91 and emotion dysregulation
Figure 2: Summary of the clinical assessment process for
children
ADHD=attention defi cit hyperactivity disorder.
Obtain detailed clinical history from parents or carers and
young person
Carry out core ADHD symptom enquiry: are symptoms out of
keeping with
child's age and developmental stage?
Obtain information across settings; consider questionnaires as
an adjunct
19. Screen for associated difficulties (eg, mental health symptoms,
other
neurodevelopmental or learning problems)
• Developmental history (eg, motor delay)
• Medical history (eg, epilepsy)
• Family history (eg, mental health, educational history,
physical health
problems)
• Medical histories especially important in relation to cardiac or
other risk
factors if pharmacological treatment is being considered
Consider severity of symptoms, effects on functioning,
comorbid symptoms,
medical history, and the family and child's strengths, resources,
demands, and
psychosocial context when deciding on treatment options
Physical assessment:
• Signs of other disorders (eg, dysmorphic features, skin
lesions) and motor
coordination (eg, handwriting, balance); to be undertaken more
completely
if considering pharmacological treatment
• Baseline height, weight, blood pressure, pulse
Seminar
20. www.thelancet.com Vol 387 March 19, 2016 1245
symptoms (eg, irritability),92 both of which can further
complicate the presentation and interpretation of
symptoms. In practice, it will be rare to fi nd an
individual who presents with so-called uncomplicated
ADHD, even if full diagnostic criteria for other
comorbid disorders are not met. This situation makes
formalising diff erential diagnoses conceptually diffi cult,
because in reality an individual with neurodevelopmental
problems is unlikely to have a pure presentation of any
one condition as a unifying explanation for their
diffi culties. A formulation should capture the full
range of developmental, behavioural, and psychiatric
diffi culties, even if some of these need to be described
in terms of subthreshold problems.
Neuropsychological testing does not have a role in
diagnosis of ADHD because cognitive processes are not a
defi ning characteristic.66 However, cognitive comorbidities
such as learning disability and dyslexia should be
considered, which may require specialist assessment
from education services.
Treatment
There are specifi c guidelines for the stepwise
management of ADHD, such as those developed by the
National Institute for Health and Care Excellence
(NICE)7 and the Scottish Intercollegiate Guidelines
Network (SIGN)93 in the UK, by the Eunethydis European
ADHD Guidelines Group (EAGG)94 in Europe, and by
the American Academy of Pediatrics (AAP)95 and the
American Academy of Child and Adolescent Psychiatry
(AACAP)96 in the USA. The main diff erence between
these guidelines is that US guidance does not preclude
the use of pharmacological treatment for preschool
21. children or for those with mild ADHD; practice that is
not recommended in Europe where a stepwise approach
is recommended. If pharmacological treatment is
prescribed, it should be in conjunction with behavioural
interventions—namely, optimised classroom manage-
ment strategies, parental psycho education, and behav-
ioural management tech niques. However, there is no
one-size-fi ts-all solution to management. Individual
circumstances such as current academic or employment
demands and medical history should be taken into
account, and appropriate evidence-based treatments for
comorbidities should also be initiated.
Non-pharmacological interventions have been
investigated extensively over the years. The only non-
pharma cological interventions that currently form a core
part of treatment guidelines are behavioural inter-
ventions. Initial results from the largest trial of ADHD
interventions so far, the multimodal treatment study of
children with ADHD (MTA),97 suggested that the
combination of intensive behavioural treatment plus
pharmacological treatment did not off er additional
benefi t over pharmacological treatment alone for core
ADHD symptoms, but that the combination might have
provided some benefi t in terms of associated symptoms
and levels of functioning as well as the need for a lower
drug dose. In a more recent series of meta-analyses
investigating randomised controlled trials of non-
pharmacological interventions, the investigators
concluded that, along with neurofeedback, cognitive
training, and restricted elimination diets, behavioural
interventions cannot be recommended as interventions
for core ADHD symptoms until better evidence of their
eff ectiveness is reported by blinded assessments.98
Elimination of artifi cial food colouring98 might be
22. benefi cial, but to what extent and for which population
of patients is unclear.99 A meta-analysis has shown that
children with ADHD have lower concen trations of
omega-3 fatty acids than controls and that supple-
mentation improves ADHD symptoms to a modest
degree (an eff ect size about a quarter as large of that
seen for pharmacological treatment); but whether
subnormal blood concentrations should be the
indication for treatment is not understood.100 However,
there is evidence from blinded randomised controlled
trials of a benefi cial eff ect of behavioural interventions
on parenting and child conduct problems,101 and there is
evidence that cognitive behaviour therapy may be useful
for adults with ADHD when used in conjunction with
pharmacological treatment.102
Stimulants such as methylphenidate and dexamfetamine
are the fi rst-line pharmacological treatments for ADHD,
and the noradrenaline reuptake inhibitor atomoxetine is
the second-line treatment. Each of these treatments
increases catecholamine availability. Meta-analyses have
provided evidence for the effi cacy of stimulants for ADHD
in children,103 in children with co-occurring autism
spectrum disorder,104 and in adults.105 Although it is
recommended that ADHD is treated in individuals with
autism spectrum disorder or intellectual disability, or
both, side-eff ects of pharmacological treatment in these
individuals are more common than in those with ADHD
alone.106,107 Meta-analyses have shown benefi cial eff ects of
atomoxetine in children108 and in adults.109 Extended-
release guanfacine and extended-release clonidine are
licensed for use in the USA. Atypical antipsychotics are
not indicated for treatment of core ADHD symptoms.
Pretreatment checks, including in relation to medical
and family medical history (in particular cardiac disorders),
23. are especially important if medication is to be initiated
(fi gure 2). Height, weight, blood pressure, and pulse
should be checked at baseline before starting treatment,
and compared with normative data. It is reasonable but
not mandatory to consider the routine performance of an
ECG before starting pharmacological treatment, and the
need to do so should be at the treating clinician’s discretion,
taking into account factors such as medical history, family
medical history, and physical examination fi ndings.7,110
It is best practice to start with a low dose, titrate up
according to response, and monitor side-eff ects carefully.7
The most common side-eff ects of medications for ADHD
are shown in the table. There is no evidence that
Seminar
1246 www.thelancet.com Vol 387 March 19, 2016
pharmacological treatment for ADHD is associated with
changes in QT interval, sudden cardiac death, acute
myocardial infarction, or stroke.110 A comprehensive
review of best practice in managing adverse events
associated with pharmacological treatment for ADHD
has been published elsewhere.110 Once an optimum
response is achieved, height, weight, and growth will
need regular monitoring. NICE guidance recommends
that height is measured every 6 months in children and
young people; weight is measured 3 months and
6 months after initiation of treatment and every 6 months
thereafter in children, young people, and adults; and
height and weight in children and young people should
be plotted on a centile chart.7 Blood pressure and pulse
should also be plotted on a centile chart before and after
24. each change in dose and routinely every 3 months.7
Adverse side-eff ects of stimulant medication for ADHD
include appetite suppression and growth retardation,
which can be off set to a degree by so-called stimulant
holidays on days when symptom control is deemed less
crucial, such as weekends and holidays, and by adjusting
the timing of doses. Other side-eff ects of stimulants and
atomoxetine include gastrointestinal symptoms, cardiac
problems, insomnia, and tics (although tics are less
common with atomoxetine). Stimulants are controlled
drugs with potential for diversion for misuse, and if there
is a concern in this regard then an alternative drug may
be preferable.
Prognosis
Not only do core ADHD symptoms themselves persist,
but individuals with childhood ADHD are also at
substantial risk of adverse outcomes in adolescence
and adulthood. In this regard, ADHD behaves
dimensionally: there is no distinct threshold at which
adverse outcomes appear. A diagnosis of ADHD is
associated with low academic attainment and premature
cessation of education, and poor educational outcomes
also extend to individuals with subthreshold
symptoms.111 ADHD also predicts serious antisocial
behaviour, involvement with the police, and substance
misuse in adolescence.36
Until recently, few data for broad outcomes beyond
the third decade of life were available. However, one
long-term follow-up study has shown that childhood
ADHD (participants aged 6–12 years) is also associated
with adverse occupational, economic, and social
outcomes, antisocial personality disorder, and risk
of substance use disorders, psychiatric hospital
25. admissions, incarcerations, and mortality.112 A Danish
registry-based investigation showed substantially
increased mortality in adult life in individuals with
ADHD compared with individuals without the disorder.
This increase in mortality was mainly a result of
accidents, and was especially increased in those with
comorbid oppositional defi ant disorder, conduct
disorder, and substance misuse.113
A meta-analysis of ADHD in prison inmates showed
an estimated prevalence of 30·1% in youth prison
populations and 26·2% in adult populations, with the
risk for female prisoners being nearly as high as that for
male prisoners.114 Psychiatric comorbidity is high in
prisoners with ADHD, especially in adults.115 Although
randomised controlled trials of ADHD treatment have
reported immediate but not as yet longer term benefi ts,
there is epidemiological evidence that pharmacological
treatment might reduce criminal behaviour116 and
trauma-related visits to emergency departments.117
Most people with ADHD do not develop psychosis or a
mood disorder. The largest studies only fi nd a small
subgroup of individuals who additionally develop
schizophrenia or bipolar disorder.118,119 Evidence about
associations between ADHD and later unipolar
depression is inconsistent;112,120 this might be because
depression is more common in female patients who are
under-represented in ADHD samples.
Future research and clinical directions
The early age of onset, male preponderance, and
strong comorbidity with other childhood-onset neuro-
developmental disorders support the inclusion of
ADHD in the DSM-5 grouping of neurodevelopmental
disorders. The previous practice of not diagnosing
26. ADHD in the presence of autism spectrum disorder or
intellectual disability has been a crucial barrier to
research on aetiological and clinical overlaps and
distinctions as well as to clinical and educational
practice. Unfortunately, referral and treatment pathways
and service provision in health and education tend to be
diagnostically focused (ie, autism only or intellectual
disability only), although some clinics and services are
focusing more broadly on childhood neurodevelop-
mental disorders, a change which is welcomed and
supported by research.
Methylphenidate
(MPH)
Atomoxetine
(ATX)
Loss of appetite + +
Growth restriction ++ +
Other gastrointestinal symptoms: abdominal pain, nausea,
vomiting,
diarrhoea (MPH), constipation (ATX), dyspepsia, dry mouth
+ +
Increase in blood pressure and heart rate + +
Cough, nasopharyngitis + ··
Sleep disturbances ++ +
Tics + ··
27. Irritability, mood changes + +
Drowsiness + ++
Dizziness + +
Headache ++ +
+=common side-eff ect. ++=if the side-eff ect is common for
both drugs, the eff ect is more pronounced for this drug
compared with the other. ··=side-eff ect not common.
Table: Some of the more common side-eff ects associated with
pharmacological treatment
Seminar
www.thelancet.com Vol 387 March 19, 2016 1247
We accept that for clinical practice, there is a need
for strict categories, otherwise diagnostic spread would
become at best unhelpful and at worst risky and
unethical (eg, use of pharmacological treatment where
not indicated) and application of evidence-based
treatments would become impossible (eg, interpreting
the severity of diffi culties of individuals included in a
trial). However, for aetiological and outcome research
purposes, there is strong evidence in favour of viewing
ADHD dimensionally. At present, we do not know what
sorts of dimensions best capture ADHD and at what
level they should be measured—eg, reported symptoms,
cognitive tests, brain imaging markers, or other
biological signatures.
28. Genetic research is progressing via large-scale
collaboration, but there is a need to understand the
clinical as well as biological meaning of fi ndings, if they
are to aff ect our understanding and treatment of ADHD.
Currently, there is no rationale for routine genetic
testing in ADHD because of limited predictive power.
However, because the disorder is heritable, rates of
ADHD in parents of those with ADHD are increased.
A pertinent future research question is how might
treatment of parent ADHD aff ect child ADHD features
and comorbidity? There is, for example, evidence that
treating parent depression seems to improve off spring
mental health.121,122 Another issue for future consideration
is that genetic and environmental risk factors that cause
ADHD are not necessarily the same as those that alter
the later course of the disorder or contribute to adverse
outcomes. What is greatly needed is research that tests
which environmental risks (eg, social and other
potentially modifi able risk factors) contribute to and
modify the longitudinal course of ADHD across time,
including better prognosis, with designs that can control
for unmeasured confounders and genetic contributions
from the aff ected person (eg, twin studies) and related
parents (eg, adoption studies). This could inform
interventions aimed at optimising outcomes.
So far, pharmacological and behavioural treatments for
ADHD have focused on symptomatic relief of the core
symptoms of inattention, overactivity, and impulsivity.
However, according to trial-based data, benefi ts seem to
be short-lived. Another issue is that treatment typically
begins after a child has already begun to fail across
multiple domains. ADHD in many respects behaves like
a chronic medical disorder. Many features remain
problematic long term, although the most prominent or
presenting features can change with age and development.
29. ADHD creates risks of its own and secondary mental
health problems commonly arise in mid-childhood and
after puberty. Almost certainly, for many individuals,
multimodal interventions that are carefully adjusted over
time to prevent complications will be needed, perhaps in
the way that is undertaken for optimising diabetes
control. How ADHD is best managed across the lifespan
and across key transition periods (eg, school entry,
comprehensive or high-school entry, transition to adult
services, and transition to parenthood) needs much more
investigation. Until now, guidelines have been based on
evidence, but unless research keeps pace, guidance will
have to be based on professional consensus, which is not
very satisfactory for a prevalent, impairing disorder.
Conclusions
ADHD is a very important condition because of its high
prevalence, persistence into adult life, and adverse
outcomes that extend beyond the aff ected individual.
Although ADHD is still viewed with scepticism by some
and often remains stigmatised by the media, the evidence
for it being a clinically and biologically meaningful entity
is robust and consistent across design type and sample.
There are established assessment methods and good
treatment evidence. However, as is true for any chronic
disorder, repeated assessment is likely to be needed and
treatment will typically need many adjustments over
time. Impairments beyond core diagnostic criteria,
developmental change, and an individual’s psychosocial
strengths, weaknesses, and resources are all important
aspects for consideration.
Contributors
AT drafted the initial outline and structure and wrote the fi rst
draft of
the summary and sections on introduction, defi nitions of
30. ADHD,
epidemiology, early comorbidity, genetics, environment and
gene–environment interplay, and future research and clinical
directions. MC wrote the fi rst draft of the sections on
pathophysiology,
clinical assessment, treatment, and prognosis, and prepared the
table,
panel, and fi gures. Both authors undertook scientifi c literature
searches
and edited the manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
We have been funded by the MRC, ESRC, and the Wellcome
Trust.
References
1 American Psychiatric Association. Diagnostic and statistical
manual
of mental disorders, 4th edition. Washington: American
Psychiatric
Association, 1994.
2 American Psychiatric Association. Diagnostic and statistical
manual
of mental disorders, 5th edition. Washington: American
Psychiatric
Association, 2013.
3 WHO. International statistical classifi cation of diseases and
related
health problems, 10th revision. Geneva: World Health
Organization, 1992.
31. 4 Ford T, Goodman R, Meltzer H. The British Child and
Adolescent
Mental Health Survey 1999: the prevalence of DSM-IV
disorders.
J Am Acad Child Adolesc Psychiatry 2003; 42: 1203–11.
5 Willcutt EG, Nigg JT, Pennington BF, et al. Validity of DSM-
IV
attention defi cit/hyperactivity disorder symptom dimensions
and
subtypes. J Abnorm Psychol 2012; 121: 991–1010.
6 Bussing R, Mason DM, Bell L, et al. Adolescent outcomes of
childhood
attention-defi cit/hyperactivity disorder in a diverse community
sample. J Am Acad Child Adolesc Psychiatry 2010; 49: 595–
605.
7 National Institute for Health and Care Excellence. Clinical
guideline 72: Attention defi cit hyperactivity disorder:
diagnosis and
management of ADHD in children, young people and adults.
Issued September, 2008, last modifi ed March, 2013.
https://www.
nice.org.uk/guidance/cg72 (accessed Aug 12, 2015).
8 Wise J. Use clinical tests to diagnose asthma and to avoid
overdiagnosis, says NICE. BMJ 2015; 350: h522.
9 Polanczyk GV, Salum GA, Sugaya LS, et al. Annual research
review:
a meta-analysis of the worldwide prevalence of mental disorders
in
children and adolescents. J Child Psychol Psychiatry 2015; 56:
345–65.
32. Seminar
1248 www.thelancet.com Vol 387 March 19, 2016
10 Meltzer H, Gatward R, Goodman R, et al. Mental health of
children
and adolescents in Great Britain. Int Rev Psychiatry 2003;
15: 185–87.
11 Polanczyk G, de Lima MS, Horta BL, et al. The worldwide
prevalence of ADHD: a systematic review and metaregression
analysis. Am J Psychiatry 2007; 164: 942–48.
12 Still GF. The Goulstonian lectures on some abnormal
psychical
conditions in children. Lancet 1902; 159: 1008–13.
13 Polanczyk GV, Willcutt EG, Salum GA, et al. ADHD
prevalence
estimates across three decades: an updated systematic review
and
meta-regression analysis. Int J Epidemiol 2014; 43: 434–42.
14 Collishaw S. Annual research review: secular trends in child
and
adolescent mental health. J Child Psychol Psychiatry 2015;
56: 370–93.
15 Štuhec M, Locatelli I, Švab V. Trends in attention-defi
cit/hyperactivity
disorder drug consumption in children and adolescents in
Slovenia
from 2001 to 2012: a drug use study from a national
33. perspective.
J Child Adolesc Psychopharmacol 2015; 25: 254–49.
16 Dalsgaard S, Nielsen HS, Simonsen M. Five-fold increase in
national prevalence rates of attention-defi cit/hyperactivity
disorder
medications for children and adolescents with autism spectrum
disorder, attention-defi cit/hyperactivity disorder, and other
psychiatric disorders: a Danish register-based study.
J Child Adolesc Psychopharmacol 2013; 23: 432–39.
17 McCarthy S, Wilton L, Murray ML, et al. The epidemiology
of
pharmacologically treated attention defi cit hyperactivity
disorder
(ADHD) in children, adolescents and adults in UK primary care.
BMC Pediatr 2012; 12: 78.
18 Sayal K, Taylor E, Beecham J, et al. Pathways to care in
children at
risk of attention-defi cit hyperactivity disorder. Br J Psychiatry
2002;
181: 43–48.
19 Sellers R, Maughan B, Pickles A, et al. Trends in parent- and
teacher-rated emotional, conduct and ADHD problems and their
impact in prepubertal children in Great Britain: 1999–2008.
J Child Psychol Psychiatry 2015; 56: 49–57.
20 Sayal K, Ford T, Goodman R. Trends in recognition of and
service
use for attention-defi cit hyperactivity disorder in Britain,
1999–2004.
Psychiatr Serv 2010; 61: 803–10.
21 Tremmery S, Buitelaar JK, Steyaert J, et al. The use of
34. health care
services and psychotropic medication in a community sample of
9-year-old schoolchildren with ADHD. Eur Child Adolesc
Psychiatry
2007; 16: 327–36.
22 Thomas R, Sanders S, Doust J, et al. Prevalence of attention-
defi cit/
hyperactivity disorder: a systematic review and meta-analysis.
Pediatrics 2015; 135: e994–1001.
23 Angold A, Erkanli A, Egger HL, et al. Stimulant treatment
for
children: a community perspective. J Am Acad Child Adolesc
Psychiatry
2000; 39: 975–84.
24 Biederman J, Kwon A, Aleardi M, et al. Absence of gender
eff ects
on attention defi cit hyperactivity disorder: fi ndings in
nonreferred
subjects. Am J Psychiatry 2005; 162: 1083–89.
25 Thapar A, Rutter M. Neurodevelopmental disorders. In:
Thapar A,
Pine DS, Leckman JF, et al, eds. Rutter’s child and adolescent
psychiatry, 6th edition. Oxford: John Wiley and Sons Limited,
2015.
26 Faraone SV, Biederman J, Mick E. The age-dependent
decline of
attention defi cit hyperactivity disorder: a meta-analysis of
follow-up
studies. Psychol Med 2006; 36: 159–65.
27 Simon V, Czobor P, Bálint S, et al. Prevalence and correlates
35. of
adult attention-defi cit hyperactivity disorder: meta-analysis.
Br J Psychiatry 2009; 194: 204–11.
28 Moffi tt TE, Houts R, Asherson P, et al. Is adult ADHD a
childhood-onset neurodevelopmental disorder? Evidence from a
four-decade longitudinal cohort study. Am J Psychiatry 2015;
published online May 22. DOI:10.1176/appi.ajp.2015.14101266.
29 Hall CL, Newell K, Taylor J, et al. Services for young
people with
attention defi cit/hyperactivity disorder transitioning from child
to
adult mental health services: a national survey of mental health
trusts in England. J Psychopharmacol 2015; 29: 39–42.
30 Lichtenstein P, Carlström E, Råstam M, et al. The genetics
of
autism spectrum disorders and related neuropsychiatric
disorders
in childhood. Am J Psychiatry 2010; 167: 1357–63.
31 Jensen CM, Steinhausen H-C. Comorbid mental disorders in
children and adolescents with attention-defi cit/hyperactivity
disorder
in a large nationwide study. Atten Defi c Hyperact Disord 2015;
7: 27–38.
32 Ahuja A, Martin J, Langley K, et al. Intellectual disability in
children
with attention defi cit hyperactivity disorder. J Pediatr 2013;
163: 890–5, e1.
33 Woodward L, Dowdney L, Taylor E. Child and family factors
infl uencing the clinical referral of children with hyperactivity:
a research note. J Child Psychol Psychiatry 1997; 38: 479–85.
36. 34 Taylor E, Chadwick O, Heptinstall E, et al. Hyperactivity
and
conduct problems as risk factors for adolescent development.
J Am Acad Child Adolesc Psychiatry 1996; 35: 1213–26.
35 Moffi tt TE. Juvenile delinquency and attention defi cit
disorder:
boys’ developmental trajectories from age 3 to age 15. Child
Dev
1990; 61: 893–910.
36 Langley K, Fowler T, Ford T, et al. Adolescent clinical
outcomes for
young people with attention-defi cit hyperactivity disorder.
Br J Psychiatry 2010; 196: 235–40.
37 Faraone SV, Biederman J, Monuteaux MC. Toward
guidelines for
pedigree selection in genetic studies of attention defi cit
hyperactivity disorder. Genet Epidemiol 2000; 18: 1–16.
38 Thapar A, Cooper M, Eyre O, et al. What have we learnt
about the
causes of ADHD? J Child Psychol Psychiatry 2013; 54: 3–16.
39 State M, Thapar A. Genetics. In: Thapar A, Pine DS,
Leckman JF,
et al, eds. Rutter’s child and adolescent psychiatry, 6th edition.
Oxford: John Wiley and Sons Limited, 2015.
40 Hamshere ML, Langley K, Martin J, et al. High loading of
polygenic
risk for ADHD in children with comorbid aggression. Am J
Psychiatry
2013; 170: 909–16.
37. 41 Williams NM, Zaharieva I, Martin A, et al. Rare
chromosomal
deletions and duplications in attention-defi cit hyperactivity
disorder:
a genome-wide analysis. Lancet 2010; 376: 1401–08.
42 Faraone SV, Perlis RH, Doyle AE, et al. Molecular genetics
of
attention-defi cit/hyperactivity disorder. Biol Psychiatry 2005;
57: 1313–23.
43 Gizer IR, Ficks C, Waldman ID. Candidate gene studies of
ADHD:
a meta-analytic review. Hum Genet 2009; 126: 51–90.
44 Kendler KS. What psychiatric genetics has taught us about
the
nature of psychiatric illness and what is left to learn. Mol
Psychiatry
2013; 18: 1058–66.
45 Cross-Disorder Group of the Psychiatric Genomics
Consortium.
Identifi cation of risk loci with shared eff ects on fi ve major
psychiatric disorders: a genome-wide analysis. Lancet 2013;
381: 1371–79.
46 Wray NR, Lee SH, Mehta D, et al. Research review:
polygenic
methods and their application to psychiatric traits.
J Child Psychol Psychiatry 2014; 55: 1068–87.
47 Lionel AC, Crosbie J, Barbosa N, et al. Rare copy number
variation
discovery and cross-disorder comparisons identify risk genes
38. for
ADHD. Sci Transl Med 2011; 3: 95ra75.
48 Bastain TM, Lewczyk CM, Sharp WS, et al. Cytogenetic
abnormalities in attention-defi cit/hyperactivity disorder.
J Am Acad Child Adolesc Psychiatry 2002; 41: 806–10.
49 Rutter M. Achievements and challenges in the biology of
environmental eff ects. Proc Natl Acad Sci USA 2012;
109 (suppl 2): 17149–53.
50 Kraemer HC, Stice E, Kazdin A, et al. How do risk factors
work
together? Mediators, moderators, and independent, overlapping,
and proxy risk factors. Am J Psychiatry 2001; 158: 848–56.
51 Bhutta AT, Cleves MA, Casey PH, et al. Cognitive and
behavioral
outcomes of school-aged children who were born preterm:
a meta-analysis. JAMA 2002; 288: 728–37.
52 Liew Z, Ritz B, Rebordosa C, et al. Acetaminophen use
during
pregnancy, behavioral problems, and hyperkinetic disorders.
JAMA Pediatr 2014; 168: 313–20.
53 Thompson JMD, Waldie KE, Wall CR, et al, and the ABC
study
group. Associations between acetaminophen use during
pregnancy
and ADHD symptoms measured at ages 7 and 11 years. PLoS
One
2014; 9: e108210.
54 Thapar A, Rutter M. Using natural experiments and animal
models
39. to study causal hypotheses in relation to child mental health
problems. In: Thapar A, Pine D, Leckman JF, et al, eds. Rutter’s
child and adolescent psychiatry, 6th edition. Oxford: John
Wiley and
Sons Limited, 2015.
55 Obel C, Olsen J, Henriksen TB, et al. Is maternal smoking
during
pregnancy a risk factor for hyperkinetic disorder? Findings from
a
sibling design. Int J Epidemiol 2011; 40: 338–45.
Seminar
www.thelancet.com Vol 387 March 19, 2016 1249
56 Skoglund C, Chen Q, D’Onofrio BM, et al. Familial
confounding of
the association between maternal smoking during pregnancy and
ADHD in off spring. J Child Psychol Psychiatry 2014; 55: 61–
68.
57 Thapar A, Rice F, Hay D, et al. Prenatal smoking might not
cause
attention-defi cit/hyperactivity disorder: evidence from a novel
design. Biol Psychiatry 2009; 66: 722–27.
58 Rice F, Harold GT, Boivin J, et al. The links between
prenatal stress
and off spring development and psychopathology: disentangling
environmental and inherited infl uences. Psychol Med 2010;
40: 335–45.
59 Liff ord KJ, Harold GT, Thapar A. Parent-child hostility and
40. child
ADHD symptoms: a genetically sensitive and longitudinal
analysis.
J Child Psychol Psychiatry 2009; 50: 1468–76.
60 Schachar R, Taylor E, Wieselberg M, et al. Changes in
family function
and relationships in children who respond to methylphenidate.
J Am Acad Child Adolesc Psychiatry 1987; 26: 728–32.
61 Harold GT, Leve LD, Barrett D, et al. Biological and rearing
mother
infl uences on child ADHD symptoms: revisiting the
developmental
interface between nature and nurture. J Child Psychol
Psychiatry
2013; 54: 1038–46.
62 Kreppner JM, O’Connor TG, Rutter M, and the English and
Romanian Adoptees Study Team. Can inattention/overactivity
be an
institutional deprivation syndrome? J Abnorm Child Psychol
2001;
29: 513–28.
63 Rutter M, Kreppner J, Croft C, et al. Early adolescent
outcomes of
institutionally deprived and non-deprived adoptees. III.
Quasi-autism. J Child Psychol Psychiatry 2007; 48: 1200–07.
64 Sontag TA, Tucha O, Walitza S, et al. Animal models of
attention
defi cit/hyperactivity disorder (ADHD): a critical review.
Atten Defi c Hyperact Disord 2010; 2: 1–20.
65 Russell VA. Overview of animal models of attention defi cit
41. hyperactivity disorder (ADHD). Curr Protoc Neurosci 2011;
9: Unit9.35.
66 Willcutt EG, Doyle AE, Nigg JT, et al. Validity of the
executive
function theory of attention-defi cit/hyperactivity disorder:
a meta-analytic review. Biol Psychiatry 2005; 57: 1336–46.
67 Noreika V, Falter CM, Rubia K. Timing defi cits in
attention-defi cit/
hyperactivity disorder (ADHD): evidence from neurocognitive
and
neuroimaging studies. Neuropsychologia 2013; 51: 235–66.
68 Rhodes SM, Park J, Seth S, et al. A comprehensive
investigation of
memory impairment in attention defi cit hyperactivity disorder
and
oppositional defi ant disorder. J Child Psychol Psychiatry 2012;
53: 128–37.
69 Kofl er MJ, Rapport MD, Sarver DE, et al. Reaction time
variability
in ADHD: a meta-analytic review of 319 studies. Clin Psychol
Rev
2013; 33: 795–811.
70 DeVito EE, Blackwell AD, Kent L, et al. The eff ects of
methylphenidate on decision making in attention-defi cit/
hyperactivity disorder. Biol Psychiatry 2008; 64: 636–39.
71 Coghill DR, Seth S, Matthews K. A comprehensive
assessment of
memory, delay aversion, timing, inhibition, decision making
and
variability in attention defi cit hyperactivity disorder:
42. advancing
beyond the three-pathway models. Psychol Med 2014; 44: 1989–
2001.
72 Coghill DR, Hayward D, Rhodes SM, et al. A longitudinal
examination of neuropsychological and clinical functioning in
boys
with attention defi cit hyperactivity disorder (ADHD):
improvements
in executive functioning do not explain clinical improvement.
Psychol Med 2014; 44: 1087–99.
73 van Lieshout M, Luman M, Buitelaar J, et al. Does
neurocognitive
functioning predict future or persistence of ADHD? A
systematic
review. Clin Psychol Rev 2013; 33: 539–60.
74 Coghill DR, Seth S, Pedroso S, et al. Eff ects of
methylphenidate on
cognitive functions in children and adolescents with attention-
defi cit/hyperactivity disorder: evidence from a systematic
review
and a meta-analysis. Biol Psychiatry 2014; 76: 603–15.
75 Cortese S, Kelly C, Chabernaud C, et al. Toward systems
neuroscience of ADHD: a meta-analysis of 55 fMRI studies.
Am J Psychiatry 2012; 169: 1038–55.
76 Frodl T, Skokauskas N. Meta-analysis of structural MRI
studies in
children and adults with attention defi cit hyperactivity disorder
indicates treatment eff ects. Acta Psychiatr Scand 2012; 125:
114–26.
77 van Ewijk H, Heslenfeld DJ, Zwiers MP, et al. Diff usion
43. tensor
imaging in attention defi cit/hyperactivity disorder: a systematic
review and meta-analysis. Neurosci Biobehav Rev 2012; 36:
1093–106.
78 Greven CU, Bralten J, Mennes M, et al. Developmentally
stable
whole-brain volume reductions and developmentally sensitive
caudate and putamen volume alterations in those with
attention-defi cit/hyperactivity disorder and their unaff ected
siblings. JAMA Psychiatry 2015; 72: 490–99.
79 Cortese S, Castellanos FX. Neuroimaging of attention-defi
cit/
hyperactivity disorder: current neuroscience-informed
perspectives
for clinicians. Curr Psychiatry Rep 2012; 14: 568–78.
80 Shaw P, Gogtay N, Rapoport J. Childhood psychiatric
disorders as
anomalies in neurodevelopmental trajectories. Hum Brain Mapp
2010; 31: 917–25.
81 Schweren LJS, de Zeeuw P, Durston S. MR imaging of the
eff ects
of methylphenidate on brain structure and function in
attention-defi cit/hyperactivity disorder. Eur
Neuropsychopharmacol
2013; 23: 1151–64.
82 Proal E, Reiss PT, Klein RG, et al. Brain gray matter defi
cits at 33-year
follow-up in adults with attention-defi cit/hyperactivity disorder
established in childhood. Arch Gen Psychiatry 2011; 68: 1122–
34.
44. 83 Cortese S, Imperati D, Zhou J, et al. White matter alterations
at
33-year follow-up in adults with childhood attention-defi cit/
hyperactivity disorder. Biol Psychiatry 2013; 74: 591–98.
84 Goodman R. The strengths and diffi culties questionnaire:
a research note. J Child Psychol Psychiatry 1997; 38: 581–86.
85 Conners CK. A teacher rating scale for use in drug studies
with
children. Am J Psychiatry 1969; 126: 884–88.
86 Goodman R, Ford T, Richards H, et al. The Development and
Well-Being Assessment: description and initial validation of an
integrated assessment of child and adolescent psychopathology.
J Child Psychol Psychiatry 2000; 41: 645–55.
87 Sexton CC, Gelhorn HL, Bell JA, et al. The co-occurrence of
reading
disorder and ADHD: epidemiology, treatment, psychosocial
impact,
and economic burden. J Learn Disabil 2012; 45: 538–64.
88 Fliers E, Vermeulen S, Rijsdijk F, et al. ADHD and poor
motor
performance from a family genetic perspective.
J Am Acad Child Adolesc Psychiatry 2009; 48: 25–34.
89 Kurlan R, Como PG, Miller B, et al. The behavioral
spectrum of tic
disorders: a community-based study. Neurology 2002; 59: 414–
20.
90 Rommelse NNJ, Franke B, Geurts HM, et al. Shared
heritability of
attention-defi cit/hyperactivity disorder and autism spectrum
45. disorder. Eur Child Adolesc Psychiatry 2010; 19: 281–95.
91 Dykens EM. Annotation. Psychopathology in children with
intellectual disability. J Child Psychol Psychiatry 2000; 41:
407–17.
92 Shaw P, Stringaris A, Nigg J, et al. Emotion dysregulation in
attention
defi cit hyperactivity disorder. Am J Psychiatry 2014; 171: 276–
93.
93 Scottish Intercollegiate Guidelines Network. Management of
attention defi cit and hyperkinetic disorders in children and
young
people. 2009. http://www.sign.ac.uk/guidelines/fulltext/112/
(accessed Aug 12, 2015).
94 Taylor E, Döpfner M, Sergeant J, et al. European clinical
guidelines
for hyperkinetic disorder—fi rst upgrade.
Eur Child Adolesc Psychiatry 2004; 13 (suppl 1): I7–30.
95 Wolraich M, Brown L, Brown RT, et al, and the
Subcommittee on
Attention-Defi cit/Hyperactivity Disorder, and the Steering
Committee on Quality Improvement and Management. ADHD:
clinical practice guideline for the diagnosis, evaluation, and
treatment of attention-defi cit/hyperactivity disorder in children
and
adolescents. Pediatrics 2011; 128: 1007–22.
96 Pliszka S, and the AACAP Work Group on Quality Issues.
Practice
parameter for the assessment and treatment of children and
adolescents with attention-defi cit/hyperactivity disorder.
J Am Acad Child Adolesc Psychiatry 2007; 46: 894–921.
46. 97 The MTA Cooperative Group. Multimodal Treatment Study
of
Children with ADHD. A 14-month randomized clinical trial of
treatment strategies for attention-defi cit/hyperactivity disorder.
Arch Gen Psychiatry 1999; 56: 1073–86.
98 Sonuga-Barke EJS, Brandeis D, Cortese S, et al, and the
European
ADHD Guidelines Group. Nonpharmacological interventions for
ADHD: systematic review and meta-analyses of randomized
controlled trials of dietary and psychological treatments.
Am J Psychiatry 2013; 170: 275–89.
99 Stevenson J, Buitelaar J, Cortese S, et al. Research review:
the role of
diet in the treatment of attention-defi cit/hyperactivity
disorder—an
appraisal of the evidence on effi cacy and recommendations on
the
design of future studies. J Child Psychol Psychiatry 2014; 55:
416–27.
Seminar
1250 www.thelancet.com Vol 387 March 19, 2016
100 Hawkey E, Nigg JT. Omega-3 fatty acid and ADHD: blood
level
analysis and meta-analytic extension of supplementation trials.
Clin Psychol Rev 2014; 34: 496–505.
101 Daley D, van der Oord S, Ferrin M, et al. Behavioral
interventions in
47. attention-defi cit/hyperactivity disorder: a meta-analysis of
randomized controlled trials across multiple outcome domains.
J Am Acad Child Adolesc Psychiatry 2014; 53: 835–47, e1–5.
102 Mongia M, Hechtman L. Cognitive behavior therapy for
adults with
attention-defi cit/hyperactivity disorder: a review of recent
randomized controlled trials. Curr Psychiatry Rep 2012; 14:
561–67.
103 Faraone SV, Buitelaar J. Comparing the effi cacy of
stimulants for
ADHD in children and adolescents using meta-analysis.
Eur Child Adolesc Psychiatry 2010; 19: 353–64.
104 Reichow B, Volkmar FR, Bloch MH. Systematic review and
meta-analysis of pharmacological treatment of the symptoms of
attention-defi cit/hyperactivity disorder in children with
pervasive
developmental disorders. J Autism Dev Disord 2013; 43: 2435–
41.
105 Moriyama TS, Polanczyk GV, Terzi FS, et al.
Psychopharmacology and
psychotherapy for the treatment of adults with ADHD-a
systematic
review of available meta-analyses. CNS Spectr 2013; 18: 296–
306.
106 Research Units on Pediatric Psychopharmacology Autism
Network.
Randomized, controlled, crossover trial of methylphenidate in
pervasive developmental disorders with hyperactivity.
Arch Gen Psychiatry 2005; 62: 1266–74.
107 Simonoff E, Taylor E, Baird G, et al. Randomized
48. controlled
double-blind trial of optimal dose methylphenidate in children
and
adolescents with severe attention defi cit hyperactivity disorder
and
intellectual disability. J Child Psychol Psychiatry 2013; 54:
527–35.
108 Bushe CJ, Savill NC. Systematic review of atomoxetine
data in
childhood and adolescent attention-defi cit hyperactivity
disorder
2009–2011: focus on clinical effi cacy and safety. J
Psychopharmacol
2014; 28: 204–11.
109 Asherson P, Bushe C, Saylor K, et al. Effi cacy of
atomoxetine in
adults with attention defi cit hyperactivity disorder: an
integrated
analysis of the complete database of multicenter placebo-
controlled
trials. J Psychopharmacol 2014; 28: 837–46.
110 Cortese S, Holtmann M, Banaschewski T, et al, and the
European
ADHD Guidelines Group. Practitioner review: current best
practice
in the management of adverse events during treatment with
ADHD
medications in children and adolescents. J Child Psychol
Psychiatry
2013; 54: 227–46.
111 Loe IM, Feldman HM. Academic and educational outcomes
of
49. children with ADHD. J Pediatr Psychol 2007; 32: 643–54.
112 Klein RG, Mannuzza S, Olazagasti MAR, et al. Clinical and
functional outcome of childhood attention-defi cit/hyperactivity
disorder 33 years later. Arch Gen Psychiatry 2012; 69: 1295–
303.
113 Dalsgaard S, Øtergaard SD, Leckman JF, et al. Mortality in
children,
adolescents, and adults with attention defi cit hyperactivity
disorder:
a nationwide cohort study. Lancet 2015; 385: 2190–96.
114 Young S, Moss D, Sedgwick O, et al. A meta-analysis of
the
prevalence of attention defi cit hyperactivity disorder in
incarcerated
populations. Psychol Med 2014; 2014: 1–12.
115 Young S, Sedgwick O, Fridman M, et al. Co-morbid
psychiatric
disorders among incarcerated ADHD populations: a meta-
analysis.
Psychol Med 2015; 2015: 1–12.
116 Lichtenstein P, Halldner L, Zetterqvist J, et al. Medication
for
attention defi cit-hyperactivity disorder and criminality. N Engl
J Med
2012; 367: 2006–14.
117 Man KKC, Chan EW, Coghill D, et al. Methylphenidate and
the risk
of trauma. Pediatrics 2015; 135: 40–48.
118 Dalsgaard S, Mortensen PB, Frydenberg M, et al.
50. Association
between attention-defi cit hyperactivity disorder in childhood
and
schizophrenia later in adulthood. Eur Psychiatry 2014; 29: 259–
63.
119 Galanter CA, Leibenluft E. Frontiers between attention defi
cit
hyperactivity disorder and bipolar disorder.
Child Adolesc Psychiatr Clin N Am 2008; 17: 325–46, viii–ix.
120 Angold A, Costello EJ, Erkanli A. Comorbidity.
J Child Psychol Psychiatry 1999; 40: 57–87.
121 Weissman MM, Pilowsky DJ, Wickramaratne PJ, et al, and
the
STAR*D-Child Team. Remissions in maternal depression and
child
psychopathology: a STAR*D-child report. JAMA 2006; 295:
1389–98.
122 Weissman MM, Wickramaratne P, Pilowsky DJ, et al.
Treatment of
maternal depression in a medication clinical trial and its eff ect
on
children. Am J Psychiatry 2015; 172: 450–59.
Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.
Attention deficit hyperactivity disorderIntroductionDefinitions
of ADHDEpidemiologyEarly comorbidityRisk
factorsOverviewGeneticsEnvironment and gene–environment
interplayPathophysiologyBiologyCognitionImagingClinical
51. assessmentTreatmentPrognosisFuture research and clinical
directionsConclusionsAcknowledgmentsReferences
P
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C
ro
w
th
e
r
Innovation
INNOVATION
SPOTLIGHT ON
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Five “discovery skills”
separate true innovators
from the rest of us.
| by Jeffrey H. Dyer, Hal B. Gregersen,
and Clayton M. Christensen
52. The Innovator’s
DNA
hbr.org | December 2009 | Harvard Business Review 61
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62 Harvard Business Review | December 2009 | hbr.org
The Innovator’s DNA
Innovation
INNOVATION
SPOTLIGHT ON
These are questions that stump senior executives,
who understand that the ability to innovate is the
“secret sauce” of business success. Unfortunately,
most of us know very little about what makes one
person more creative than another. Perhaps for this
reason, we stand in awe of visionary entrepreneurs
like Apple’s Steve Jobs, Amazon’s Jeff Bezos, eBay’s
Pierre Omidyar, and P&G’s A.G. Lafl ey. How do
these people come up with groundbreaking new
ideas? If it were possible to discover the inner work-
ings of the masters’ minds, what could the rest of us
learn about how innovation really happens?
In searching for answers, we undertook a six-
year study to uncover the origins
of creative – and oft en disrup-
tive – business strategies in par-
53. ticularly innovative companies.
Our goal was to put innovative
entrepreneurs under the micro-
scope, examining when and how
they came up with the ideas on
which their businesses were built.
We especially wanted to examine
how they diff er from other execu-
tives and entrepreneurs: Some-
one who buys a McDonald’s fran-
chise may be an entrepreneur,
but building an Amazon requires
different skills altogether. We
studied the habits of 25 innova-
tive entrepreneurs and surveyed
more than 3,000 executives and
500 individuals who had started
innovative companies or invented
new products.
We were intrigued to learn that
at most companies, top executives
do not feel personally responsible
for coming up with strategic inno-
vations. Rather, they feel responsi-
ble for facilitating the innovation
process. In stark contrast, senior
executives of the most innovative
companies – a mere 15% in our
study – don’t delegate creative
work. They do it themselves.
But how do they do it? Our research led us to
identify fi ve “discovery skills” that distinguish the
most creative executives: associating, questioning,
observing, experimenting, and networking. We
54. found that innovative entrepreneurs (who are also
CEOs) spend 50% more time on these discovery ac-
tivities than do CEOs with no track record for in-
novation. Together, these skills make up what we
call the innovator’s DNA. And the good news is, if
you’re not born with it, you can cultivate it.
What Makes Innovators Different?
Innovative entrepreneurs have something called
creative intelligence, which enables discovery yet
diff ers from other types of intelligence (as sug-
gested by Howard Gardner’s theory of multiple
intelligences). It is more than the cognitive skill of
being right-brained. Innovators engage both sides
of the brain as they leverage the fi ve discovery skills
to create new ideas.
In thinking about how these skills work together,
we’ve found it useful to apply the metaphor of DNA.
Associating is like the backbone structure of DNA’s
double helix; four patterns of action (questioning,
observing, experimenting, and networking) wind
around this backbone, helping to cultivate new in-
sights. And just as each person’s physical DNA is
unique, each individual we studied had a unique
innovator’s DNA for generating breakthrough busi-
ness ideas.
Imagine that you have an identical twin, en-
dowed with the same brains and natural talents
that you have. You’re both given one week to come
up with a creative new business-venture idea. Dur-
ing that week, you come up with ideas alone in
your room. In contrast, your twin (1) talks with 10
people – including an engineer, a musician, a stay-
at-home dad, and a designer – about the venture,
55. (2) visits three innovative start-ups to observe what
they do, (3) samples fi ve “new to the market” prod-
ucts, (4) shows a prototype he’s built to fi ve people,
and (5) asks the questions “What if I tried this?” and
“Why do you do that?” at least 10 times each day dur-
ing these networking, observing, and experiment-
ing activities. Who do you bet will come up with the
more innovative (and doable) idea?
“How do I fi nd INNOVATIVE PEOPLE
for my organization? And how can
I become more innovative myself ?”
The habits of Steve Jobs, Jeff
Bezos, and other innovative CEOs
reveal much about the underpin-
nings of their creative thinking.
Research shows that fi ve discov-
ery skills distinguish the most in-
novative entrepreneurs from other
executives.
DOING
Questioning » allows innovators
to break out of the status quo and
consider new possibilities.
Through » observing, innovators
detect small behavioral details –
in the activities of customers, sup-
pliers, and other companies – that
suggest new ways of doing things.
In » experimenting, they relent-
56. lessly try on new experiences and
explore the world.
And through » networking with
individuals from diverse back-
grounds, they gain radically
different perspectives.
THINKING
The four patterns of action »
together help innovators associate
to cultivate new insights.
IN BRIEF
IDEA
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hbr.org | December 2009 | Harvard Business Review 63
Studies of identical twins separated at birth in-
dicate that our ability to think creatively comes
one-third from genetics; but two-thirds of the in-
novation skill set comes through learning – fi rst
understanding a given skill, then practicing it, ex-
perimenting, and ultimately gaining confi dence in
one’s capacity to create. Innovative entrepreneurs
in our study acquired and honed their innovation
skills precisely this way.
Let’s look at the skills in detail.
57. Discovery Skill 1: Associating
Associating, or the ability to successfully connect
seemingly unrelated questions, problems, or ideas
from diff erent fi elds, is central to the innovator’s
DNA. Entrepreneur Frans Johansson described this
phenomenon as the “Medici eff ect,” referring to the
creative explosion in Florence when the Medici fam-
ily brought together people from a wide range of
disciplines – sculptors, scientists, poets, philosophers,
painters, and architects. As these individuals con-
nected, new ideas blossomed at the intersections of
their respective fi elds, thereby spawning the Renais-
sance, one of the most inventive eras in history.
To grasp how associating works, it is important
to understand how the brain operates. The brain
doesn’t store information like a dictionary, where
you can fi nd the word “theater” under the letter
“T.” Instead, it associates the word “theater” with
any number of experiences from our lives. Some
of these are logical (“West End” or “intermission”),
while others may be less obvious (perhaps “anxiety,”
from a botched performance in high school). The
more diverse our experience and knowledge, the
more connections the brain can make. Fresh inputs
trigger new associations; for some, these lead to
novel ideas. As Steve Jobs has frequently observed,
“Creativity is connecting things.”
The world’s most innovative companies prosper
by capitalizing on the divergent associations of
their founders, executives, and employees. For ex-
ample, Pierre Omidyar launched eBay in 1996 aft er
linking three unconnected dots: (1) a fascination
58. with creating more-effi cient markets, aft er having
been shut out from a hot internet company’s IPO in
the mid-1990s; (2) his fi ancée’s desire to locate hard-
to-fi nd collectible Pez dispensers; and (3) the inef-
fectiveness of local classifi ed ads in locating such
items. Likewise, Steve Jobs is able to generate idea
aft er idea because he has spent a lifetime exploring
new and unrelated things – the art of calligraphy,
meditation practices in an Indian ashram, the fi ne
details of a Mercedes-Benz.
Associating is like a mental muscle that can grow
stronger by using the other discovery skills. As in-
novators engage in those behaviors, they build their
ability to generate ideas that can be recombined in
new ways. The more frequently people in our study
attempted to understand, categorize, and store new
knowledge, the more easily their brains could natu-
rally and consistently make, store, and recombine
associations.
Discovery Skill 2: Questioning
More than 50 years ago, Peter Drucker described
the power of provocative questions. “The important
and diffi cult job is never to fi nd the right answers, it
is to fi nd the right question,” he wrote. Innovators
constantly ask questions that challenge common
wisdom or, as Tata Group chairman Ratan Tata
puts it, “question the unquestionable.” Meg Whit-
man, former CEO of eBay, has worked directly with
a number of innovative entrepreneurs, including
the founders of eBay, PayPal, and Skype. “They get
a kick out of screwing up the status quo,” she told
us. “They can’t bear it. So they spend a tremendous
amount of time thinking about how to change the
world. And as they brainstorm, they like to ask: ‘If
59. we did this, what would happen?’”
Most of the innovative entrepreneurs we in-
terviewed could remember the specifi c questions
they were asking at the time they had the inspira-
tion for a new venture. Michael Dell, for instance,
told us that his idea for founding Dell Computer
sprang from his asking why a computer cost fi ve
times as much as the sum of its parts. “I would take
computers apart…and would observe that $600
worth of parts were sold for $3,000.” In chewing
over the question, he hit on his revolutionary busi-
ness model.
To question eff ectively, innovative entrepreneurs
do the following:
Ask “Why?” and “Why not?” and “What if?”
Most managers focus on understanding how to
make existing processes – the status quo – work a
little better (“How can we improve widget sales in
Taiwan?”). Innovative entrepreneurs, on the other
hand, are much more likely to challenge assump-
tions (“If we cut the size or weight of the widget
in half, how would that change the value proposi-
tion it off ers?”). Marc Benioff , the founder of the
online sales soft ware provider Salesforce.com, was
full of questions aft er witnessing the emergence of
Amazon and eBay, two companies built on services
delivered via the internet. “Why are we still loading
and upgrading soft ware the way we’ve been doing
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The Innovator’s DNA
Innovation
INNOVATION
SPOTLIGHT ON
all this time when we can now do it over the inter-
net?” he wondered. This fundamental question was
the genesis of Salesforce.com.
Imagine opposites. In his book The Opposable
Mind, Roger Martin writes that innovative thinkers
have “the capacity to hold two diametrically op-
posing ideas in their heads.” He explains, “Without
panicking or simply settling for one alternative or
the other, they’re able to produce a synthesis that is
superior to either opposing idea.”
Innovative entrepreneurs like to play devil’s ad-
vocate. “My learning process has always been about
disagreeing with what I’m being told and taking
the opposite position, and pushing others to really
justify themselves,” Pierre Omidyar told us. “I re-
member it was very frustrating for the other kids
when I would do this.” Asking oneself, or others, to
imagine a completely diff erent alternative can lead
to truly original insights.
Embrace constraints. Most of us impose con-
straints on our thinking only when forced to deal
with real-world limitations, such as resource al-
locations or technology restrictions. Ironically,
great questions actively impose constraints on our
61. thinking and serve as a catalyst for out-of-the-box
insights. (In fact, one of Google’s nine innovation
principles is “Creativity loves constraint.”) To initi-
ate a creative discussion about growth opportuni-
ties, one innovative executive in our study asked
this question: “What if we were legally prohibited
from selling to our current customers? How would
we make money next year?” This led to an insight-
ful exploration of ways the company could fi nd
and serve new customers. Another innovative CEO
prods his managers to examine sunk-cost con-
straints by asking, “What if you had not already
hired this person, installed this equipment, imple-
mented this process, bought this business, or pur-
sued this strategy? Would you do the same thing
you are doing today?”
Discovery Skill 3: Observing
Discovery-driven executives produce uncommon
business ideas by scrutinizing common phenomena,
particularly the behavior of potential customers. In
observing others, they act like anthropologists and
social scientists.
Intuit founder Scott Cook hit on the idea for
Quicken fi nancial soft ware aft er two key observa-
tions. First he watched his wife’s frustration as she
struggled to keep track of their fi nances. “Oft en the
surprises that lead to new business ideas come from
watching other people work and live their normal
lives,” Cook explained. “You see something and ask,
‘Why do they do that? That doesn’t make sense.’”
Then a buddy got him a sneak peek at the Apple
Lisa before it launched. Immediately aft er leaving
Apple headquarters, Cook drove to the nearest res-
62. taurant to write down everything he had noticed
about the Lisa. His observations prompted insights
such as building the graphical user interface to look
just like its real-world counterpart (a checkbook,
for example), making it easy for people to use it.
So Cook set about solving his wife’s problem and
grabbed 50% of the market for fi nancial soft ware
in the fi rst year.
Innovators carefully, intentionally, and consis-
tently look out for small behavioral details – in the
activities of customers, suppliers, and other compa-
nies – in order to gain insights about new ways of
doing things. Ratan Tata got the inspiration that led
to the world’s cheapest car by observing the plight
of a family of four packed onto a single motorized
scooter. Aft er years of product development, Tata
Group launched in 2009 the $2,500 Nano using a
modular production method that may disrupt the
entire automobile distribution system in India. Ob-
servers try all sorts of techniques to see the world
in a diff erent light. Akio Toyoda regularly practices
Toyota’s philosophy of genchi genbutsu – “going to
the spot and seeing for yourself.” Frequent direct
observation is baked into the Toyota culture.
Discovery Skill 4: Experimenting
When we think of experiments, we think of scien-
tists in white coats or of great inventors like Thomas
Edison. Like scientists, innovative entrepreneurs ac-
tively try out new ideas by creating prototypes and
launching pilots. (As Edison said, “I haven’t failed.
I’ve simply found 10,000 ways that do not work.”)
The world is their laboratory. Unlike observers, who
intensely watch the world, experimenters construct
interactive experiences and try to provoke unortho-
63. dox responses to see what insights emerge.
The innovative entrepreneurs we interviewed all
engaged in some form of active experimentation,
whether it was intellectual exploration (Michael
Lazaridis mulling over the theory of relativity in
high school), physical tinkering (Jeff Bezos taking
apart his crib as a toddler or Steve Jobs disassem-
bling a Sony Walkman), or engagement in new
surroundings (Starbucks founder Howard Shultz
roaming Italy visiting coff ee bars). As executives
of innovative enterprises, they make experimenta-
tion central to everything they do. Bezos’s online
bookstore didn’t stay where it was aft er its initial
Sample of
Innovative
Entrepreneurs
from our Study
SAM ALLEN
ScanCafe.com
MARC BENIOFF
Salesforce.com
JEFF BEZOS
Amazon.com
MIKE COLLINS
Big Idea Group
SCOTT COOK
Intuit
MICHAEL DELL
64. Dell Computer
AARON GARRITY
XanGo
DIANE GREEN
VMWare
ELIOT JACOBSEN
RocketFuel
JOSH JAMES
Omniture
CHRIS JOHNSON
Terra Nova
JEFF JONES
NxLight; Campus
Pipeline
HERB KELLEHER
Southwest Airlines
MIKE LAZARIDIS
Research In Motion
SPENCER MOFFAT
Fast Arch of Utah
DAVID NEELEMAN
JetBlue; Morris Air
PIERRE OMIDYAR
eBay
65. JOHN PESTANA
Omniture
PETER THIEL
PayPal
MARK WATTLES
Hollywood Video
COREY WRIDE
Movie Mouth
NIKLAS
ZENNSTRÖM
Skype
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hbr.org | December 2009 | Harvard Business Review 65
success; it morphed into an online discount retailer,
selling a full line of products from toys to TVs to
home appliances. The electronic reader Kindle is
an experiment that is now transforming Amazon
from an online retailer to an innovative electron-
ics manufacturer. Bezos sees experimentation as so
critical to innovation that he has institutionalized it
at Amazon. “I encourage our employees to go down
blind alleys and experiment,” Bezos says. “If we can
get processes decentralized so that we can do a lot
of experiments without it being very costly, we’ll get
a lot more innovation.”
66. Scott Cook, too, stresses the importance of cre-
ating a culture that fosters experimentation. “Our
culture opens us to allowing lots of failures while
harvesting the learning,” he told us. “It’s what sepa-
rates an innovation culture from a normal corpo-
rate culture.”
One of the most powerful experiments innova-
tors can engage in is living and working overseas.
Our research revealed that the more countries a
person has lived in, the more likely he or she is
to leverage that experience to deliver innovative
products, processes, or businesses. In fact, if man-
agers try out even one international assignment
before becoming CEO, their companies deliver
stronger fi nancial results than companies run by
CEOs without such experience – roughly 7% higher
market performance on average. P&G’s A.G. Lafl ey,
for example, spent time as a student studying his-
tory in France and running retail operations on U.S.
military bases in Japan. He returned to Japan later
to head all of P&G’s Asia operations before becom-
ing CEO. His diverse international experience has
served him well as the leader of one of the most
innovative companies in the world.
Discovery Skill 5: Networking
Devoting time and energy to fi nding and testing
ideas through a network of diverse individuals gives
innovators a radically diff erent perspective. Unlike
most executives – who network to access resources,
to sell themselves or their companies, or to boost
their careers – innovative entrepreneurs go out of
their way to meet people with diff erent kinds of
ideas and perspectives to extend their own knowl-
67. edge domains. To this end, they make a conscious
eff ort to visit other countries and meet people from
other walks of life.
They also attend idea conferences such as Tech-
nology, Entertainment, and Design (TED), Davos,
and the Aspen Ideas Festival. Such conferences
How Innovators Stack Up
This chart shows how four well-known innovative entrepreneurs
rank
on each of the discovery skills. All our high-profi le innovators
scored
above the 80th percentile on questioning, yet each combined the
dis-
covery skills uniquely to forge new insights.
Rankings are based on
a survey of more than
3,000 executives and
entrepreneurs.
100
80
60
40
PERCENTILE
Noninnovators
68. QUESTIONINGASSOCIATING OBSERVING
EXPERIMENTING NETWORKING
Michael Dell
Michael Lazaridis
Scott Cook
Pierre Omidyar
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66 Harvard Business Review | December 2009 | hbr.org
The Innovator’s DNA
Innovation
INNOVATION
SPOTLIGHT ON
draw together artists, entrepreneurs, academics,
politicians, adventurers, scientists, and thinkers
from all over the world, who come to present their
newest ideas, passions, and projects. Michael Laza-
ridis, the founder of Research In Motion, notes that
the inspiration for the original BlackBerry occurred
at a conference in 1987. A speaker was describing
a wireless data system that had been designed for
Coke; it allowed vending machines to send a signal
when they needed refi lling. “That’s when it hit me,”
Lazaridis recalls. “I remembered what my teacher
said in high school: ‘Don’t get too caught up with
69. computers because the person that puts wireless
technology and computers together is going to
make a big diff erence.’” David Neeleman came up
with key ideas for JetBlue – such as satellite TV at
every seat and at-home reservationists – through
networking at conferences and elsewhere.
Kent Bowen, the founding scientist of CPS tech-
nologies (maker of an innovative ceramic compos-
ite), hung the following credo in every offi ce of his
start-up: “The insights required to solve many of
our most challenging problems come from outside
our industry and scientifi c fi eld. We must aggres-
sively and proudly incorporate into our work fi nd-
ings and advances which were not invented here.”
Scientists from CPS have solved numerous complex
problems by talking with people in other fi elds. One
expert from Polaroid with in-depth knowledge of
fi lm technology knew how to make the ceramic
composite stronger. Experts in sperm-freezing tech-
nology knew how to prevent ice crystal growth on
cells during freezing, a technique that CPS applied
to its manufacturing process with stunning success.
Practice, Practice, Practice
As innovators actively engage in the discovery skills,
they become defi ned by them. They grow increas-
ingly confi dent of their creative abilities. For A.G.
Lafl ey, innovation is the central job of every leader,
regardless of the place he or she occupies on the
organizational chart. But what if you – like most ex-
ecutives – don’t see yourself or those on your team
as particularly innovative?
Though innovative thinking may be innate to
70. some, it can also be developed and strengthened
through practice. We cannot emphasize enough
the importance of rehearsing over and over the
behaviors described above, to the point that they
become automatic. This requires putting aside time
for you and your team to actively cultivate more
creative ideas.
The most important skill to practice is question-
ing. Asking “Why” and “Why not” can help turbo-
charge the other discovery skills. Ask questions
that both impose and eliminate constraints;
this will help you see a problem or opportunity
from a diff erent angle. Try spending 15 to 30
minutes each day writing down 10 new ques-
tions that challenge the status quo in your com-
pany or industry. “If I had a favorite question to
ask, everyone would anticipate it,” Michael Dell
told us. “Instead I like to ask things people don’t
think I’m going to ask. This is a little cruel, but
I kind of delight in coming up with questions
that nobody has the answer to quite yet.”
To sharpen your own observational skills,
watch how certain customers experience a
product or service in their natural environ-
ment. Spend an entire day carefully observing
the “jobs” that customers are trying to get done.
Try not to make judgments about what you see:
Simply pretend you’re a fl y on the wall, and
observe as neutrally as possible. Scott Cook ad-
vises Intuit’s observers to ask, “What’s diff erent
than you expected?” Follow Richard Branson’s
example and get in the habit of note taking
wherever you go. Or follow Jeff Bezos’s: “I take
71. pictures of really bad innovations,” he told us,
“of which there are a number.”
WHY DO INNOVATORS
question, observe, experiment,
and network more than typical
executives? As we examined what
motivates them, we discovered two
common themes: (1) They actively
desire to change the status quo, and
(2) they regularly take risks to make
that change happen. Throughout our
research, we were struck by the con-
sistency of language that innovators
use to describe their motives. Jeff
Bezos wants to “make history,” Steve
Jobs to “put a ding in the universe,”
Skype cofounder Niklas Zennström
to “be disruptive, but in the cause
of making the world a better place.”
72. These innovators steer entirely clear
of a common cognitive bias called
the status quo bias – the tendency to
prefer an existing state of affairs to
alternative ones.
Embracing a mission for change
makes it much easier to take risks
and make mistakes. For most of the
innovative entrepreneurs we studied,
mistakes are nothing to be ashamed
of; in fact, they are expected as a cost
of doing business. “If the people run-
ning Amazon.com don’t make some
signifi cant mistakes,” explained Be-
zos, “then we won’t be doing a good
job for our shareholders because we
won’t be swinging for the fences.”
In short, innovators rely on their
73. “courage to innovate” – an active
bias against the status quo and an
unfl inching willingness to take
risks – to transform ideas into power-
ful impact.
Put a Ding in the Universe
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hbr.org | December 2009 | Harvard Business Review 67
To strengthen experimentation, at both the
individual and organizational levels, consciously
approach work and life with a hypothesis-testing
mind-set. Attend seminars or executive education
courses on topics outside your area of expertise;
take apart a product or process that interests you;
read books that purport to identify emerging trends.
When you travel, don’t squander the opportunity
to learn about diff erent lifestyles and local behav-
ior. Develop new hypotheses from the knowledge
you’ve acquired and test them in the search for new
products or processes. Find ways to institutional-
ize frequent, small experiments at all levels of the
organization. Openly acknowledging that learning
through failure is valuable goes a long way toward
building an innovative culture.
74. To improve your networking skills, contact the
fi ve most creative people you know and ask them
to share what they do to stimulate creative thinking.
You might also ask if they’d be willing to act as your
creative mentors. We suggest holding regular idea
lunches at which you meet a few new people from
diverse functions, companies, industries, or coun-
tries. Get them to tell you about their innovative
ideas and ask for feedback on yours.
• • •
Innovative entrepreneurship is not a genetic pre-
disposition, it is an active endeavor. Apple’s slogan
“Think Diff erent” is inspiring but incomplete. We
found that innovators must consistently act diff er-
ent to think diff erent. By understanding, reinforcing,
and modeling the innovator’s DNA, companies can
fi nd ways to more successfully develop the creative
spark in everyone.
Jeffrey H. Dyer ([email protected]) is a professor of
strategy at Brigham Young University in Provo, Utah,
and an adjunct professor at the University of Penn-
sylvania’s Wharton School. Hal B. Gregersen (hal.
[email protected]) is a professor of leadership
at Insead in Abu Dhabi, UAE, and Fontainebleau,
France. Clayton M. Christensen ([email protected]
hbs.edu) is a professor of business administration at
Harvard Business School in Boston.
Reprint R0912E To order, see page 131.
75. Try spending 15 to 30 minutes each day
writing down questions that challenge the
status quo in your company.
“The numbers aren’t working.”R
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