Hello and welcome to Pay Attention: ADHD Through the Lifespan. My name is Dr. Anthony L.

Rostain, and I'm professor of Psychiatry and Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. I'm here to present to you a course on Attention Deficit Hyperactivity Disorder. We're going to cover everything from its diagnosis and its underlying causes and neurobiology, to ways that we evaluate and treat individuals with ADHD across the lifespan. Our first week is going to focus on the basics. First of all, we have to ask the question, why is ADHD important? Well, for one thing, it is the most common neuro-behavioral disorder of childhood. It affects large numbers of children throughout the world. And we're going to talk some more about its prevalence and its epidemiology. But see, ADHD is not just a childhood disorder. It doesn't just have an impact on child development, it also affects the lifetime of individuals who suffer from ADHD. ADHD is controversial. And a number of the reasons for this have to do with the challenges of making the diagnosis. There have been changes in the terminology of the disorder, over the last hundred years or so since it's been recorded in medical literature. And there are fears of over-diagnosis and over-medicating children, that are really important for us to consider. It turns out, though, that knowledge of ADHD is evolving very rapidly. And what began as case descriptions and case studies has evolved into many, many clinical trials, both of medication and of therapies, as well as observations of behavior. That are repetitively demonstrating differences in the way people with ADHD act compared to those who don't have ADHD. Luckily, we've had wonderful advances in neuroscience that have allowed us to look inside the brain and learn more about how the brains of people with ADHD differ from the rest of the population. So, let's turn to the question, what is

ADHD? What are it's diagnostic criteria? First of all, ADHD is a behavioral disorder who's core symptoms include inattention, hyperactivity and impulsivity. These have to be present to a degree that is maladaptive and inconsistent with the individual's developmental level. So, for example, a 3 year old's attention span would be different than what we would expect from an 8 year old or a 12 year old. And if we said an individual is innattentive, we need to think about how that innattention manifests itself and whether or not it's interfearing with the child's development expectations. Secondly, there has to be chronicity of ADHD symptoms. They can't just occur for a few months. These really need to be present for a long period of time. ADHD symptoms also need to be pervasive, they need to be present not just in one setting, like school, but there needs to be evidence of the disorder in family se, setting, or in the community or in the workplace. There has to be presence of ADHD symptoms in more than one location or setting. And finally, there needs to be some evidence of impairment caused by the ADHD symptoms. Without this impairment, we might say that someone has some of the traits of ADHD, but not really the disorder as documented in the DSM-IV or the Diagnostic and Statistical Manual 4th edition of the American Psychiatric Association. So, let's look specifically now at what these diagnostic criteria look like in respect with respect to ADHD. The first has to do with 6 or more of the following symptoms of inattention that have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. So for example, often fails to give close attention to details or makes careless mistakes in school work, work, or other activities. The individual often has difficulty sustaining attention in tasks or play activity. The individual often doesn't seem to listen when spoken to directly, or they often don't follow through on instruction and don't finish chores and school work

and other duties in the workplace. Now, this can't be due to the failure to understand instructions or to being oppositional and not feeling like you want to do those chores. This is despite trying to do the chores, these individuals aren't finishing and following through. Inattention can also be manifested as having difficult organizing tasks and activities. Just not being able to get started or being able to keep track of what you're supposed to do. It can be manifested as avoiding, disliking, or being reluctant to engage in tasks that require sustained mental effort like schoolwork, or homework. I call this the laziness criteria because individual ADHD often just don't like doing things that are hard to do. We think this comes from the difficulties they have in sustaining attention. But once again, this can interfere then with their performance. Inattention can be manifested by losing things that are necessary for tasks or activities. So, children might lose their toys. If they're playing baseball, they might leave their mitts at the, at the, at the field or lose their jackets. They may lose assignments, or pencils, or books, or important tools. So, this is another manifestation of inattention. Inattention can be also noted by being distracted by extraneous stimuli. Things going on in the environment, like sounds or visual stimuli, that take the person off what they're trying to do. And finally, inattention can be manifested by being very forgetful in daily activities. Not remembering what you need to do, where to go, forgetting important appointments, forgetting important assignments. With respect to the other dimension of ADHD, the individual who meets criteria has to have at least 6 or more of the following symptoms of hyperactivity and impulsivity. Again, these have to have persisted for at least 6 months and have to be there for to a degree that is maladaptive and inconsistent with their developmental level. So, these are the symptoms, if you will, of hyperactivity.

That includes often fidgeting with hands or feet, or squirming in the seat. Often leaving the seat in the classroom or in other situations where you're expected to stay seated. Running around or climbing excessively when it's inappropriate. Now, this symptom is more prominent in children. With adolescents or adults, we would substitute the subjective feelings of restlessness for this symptom criterion. Individual may have difficulty playing or engaging in leisure activities quietly. So, making lots of noise and not being able to stay quiet is another sign of hyperactivity. Being on the goal or acting like you're driven by a motor is a hyperactive symptom. And talking excessively, to the point where others are noting that the individual is really almost a motor mouth if you will. And then, there are three symptoms of impulsivity that fall within this domain of hyperactivity impulsivity, and that in, those include blurting out answers before questions have been completed. Having difficulty awaiting your turn, and interrupting or intruding on others. For example, butting into conversations or games just not really being able to get the idea that you have to wait until there's an opening in one of those e, either a conversation or a game. Keep in mind then that all of these symptoms may be seen in any of us, and in fact, can be seen not infrequently in most of us. However, individuals with ADHD need to have these symptoms occur often and to a point that is interfering with their life. So, additional criteria for ADHD in the DSM-IV are, number one, the fact that these symptoms must have been present before age seven. Secondly, that they, there must be impairment from these symptoms in at least two settings. Thirdly, that there's clear evidence of interference with developmentally appropriate social, academic, or occupational functioning. And this is an important criterium. Because again, you may have some of these symptoms, but if its not impairing you and or interfering with developmentally appropriate functioning, then we really

can't make the diagnosis of ADHD. And last but not least, the disturbance cannot occur exclusively during the course of another serious mental disorder, such as pervasive developmental disorder or autism, schizophrenia or other psychotic disorders. Now in the current DSM, we have essentially three different ways of diagnosing ADHD. First, there's the combined type of Attention Deficit Hyperactivity Disorder. And that's, that, that's considered the case when criteria A1 and A2 are both met for the past six months. We also have Attention Deficit Hyperactivity Disorder predominantly inattentive type. And this is when criteria in A1 is met but not A2 for the past 6 months. We also have Attention Deficit Hyperactive Disorder predominately hyperactive impulsive type and that's if criteria in A2 is met but criteria in A1 is not met for the past 6 months. Now, it turns out that some individuals such as adults or adolescents who may have symptoms that don't meet full criteria. We can classify those as having ADHD in partial remission. So, I've reviewed for you the DSM-IV criteria for ADHD. What are the strengths of this pro, approach to diagnosing ADHD? Well, first of all, it uses rigorous and empirically derived criteria. These are not just randomly designed symptoms. They were actually derived from many, many studies, using many different methodologies, and using a, many different ways of approaching this phenomenon we call ADHD. It turns out that a committee of experts developed these criteria. They reviewed all of the literature of ADHD. They looked at all the rating scales that were being used to diagnose children an, an, an, and adults and adolescence and they reviewed and studied these. And finally, they conducted a field trial for the 4, 4 to 16 year old age range. And they used diagnostic cutoff points based on the reliability and ability to discriminate ADHD from non-ADHD. Last but not least, in this DSM-IV, impairment criteria is essential and must be there in order for the diagnosis to be

made. So, once again, DSM-IV criteria are rigorous, empirically derived, have been field tested and it's more than just symptoms. It's also impairment that is required for the diagnosis. This, nevertheless, our DSM-IV has certain weaknesses, and it is important to keep these in mind. First of all, we're not sure if the age of onset of 7 years is justified. In fact, there are many studies now showing that, that may be too restrictive a criteria. and I'll talk a little bit more about that when we talk about changes coming in the new version of the DSM, the DSM-V. It's also interesting that some of the item sets may not be appropriate for different developmental periods. So, while it may be appropriate to talk about children not staying in their seats this is not necessarily a relevant criterion for adults who might not necessarily have to sit in their seats. Certainly not in a classroom, and who may in fact be moving around in the normal course of their daily work. Another important weakness of the DSM-IV is that the thresholds that we use may not apply to the older age group, tho, those individuals over 16 years of age. So, while we say that you need six of nine symptoms in either of those domains to meet criterion for, to meet the criterion requirements for DSM-IV, six may not be the right amount for adults. And in DSM-V, those thresholds are being redesigned. Now, there are also no gender distinction in the diagnostic thresholds, which is a serious problem. Because girls may not be as hyperactive as boys, and therefore they may not get diagnosed as readily as having ADHD. There's also no lower age limit defined, so it's not clear what do we do about children under 4 years of age. How do we make the diagnosis in preschoolers of ADHD? The DSM-IV doesn't really help us on that, on that domain. Last, but not least, this notion of being developmentally inappropriate is not really stipulated or quantified. It may be in the eye of the beholder rather than in the objective criteria to say that this is an inappropriate behavior for this developmental age.

The, you know, development is influenced by culture, by the expectations of society, and by a number of other variables that are very difficult to quantify. And so, this remains one of the weaknesses of DSM-IV that have to be addressed. Now, beyond the weaknesses themselves, there are some controversies. and, and one of the biggest one has to do with the sub types of ADHD. First of all, they're very, very different. Having primarily inattentive type of ADHD is very different than having primarily hyperactive and impulsive type. And the fact that these subtypes are so different really has important implications for our, both our research and our clinical approaches. So, inattentive individuals have very different symptoms and life courses from those individuals who have the hyperactive and impulsive type of ADHD. Moreover, the hyperactive and impulsive type of ADHD can be confused with other disorders. So, that's a concern for all of us, that the heterogeneity of these subtypes is, is problem. Another important controversy is that the setting whether you're, and the source of information are often confounded. Now, the setting could be the school or the home and the source of information, in the case of children and adolescents could be a teacher or a parent. And these get confounded in our diagnostic criteria. It's very clear that people behave differently in different contexts, and that raters may have different criteria for judging behavior. Now, what this implies then is that, a child behaving one way in school, behaves differently at home. Those different settings may be differences of, of, of behavior, but there also may be differences in the way a teacher or a parent rates the behavior itself. And it turns out, there's a low correlation between parent and teacher ratings of child behavior. Somewhere in the order of 0.3 to 0.5, that means only at best half the time. When we ask parents and teachers to rate a child's behavior, no more than half the time do those two ratings agree.

And this, as you can imagine, leads to disagreement and to confusion. When there's clear agreement between parent and teacher, we're more convinced of the diagnosis. But, when there's a big disagreement, we're not sure what should we do in that situation. This remains one of the biggest controversies of the DSM-IV. Another important controversy is the notion of the importance of inattention in figuring out how much is this, the central problem of ADHD. For one thing, attention is not a unitary construct. You and I might use the term very differently. Attention is not the same as blood pressure, for example, and attention deficit is not the same as sort of having anemia where you have a deficit of, of red blood cells. Attention itself is a very fluid notion. And different scientists, different writers, define attention differently. Similarly, inattention is very hard to detect and measure. It's one thing to measure how much children move around. It's another thing to go about trying to measure how well they're paying attention. And it turns out that inattention can often be present in, in, in conditions other than ADHD. And it can be due to factors other than ADHD. We know very well, for example, that children who've been raised in chaotic and traumatic environments, they may become inattentive from something called Post-traumatic Stress Disorder. We also know children and adults who are depressed may not be able to pay attention because of depression or anxiety. These are just a few conditions that may lead to inattention, and therefore, might be confused with ADHD. Finally, another important controversy in the DSM-IV has to do with the relative importance of hyperactivity versus impulsivity. right now, in the DSM-IV, hyperactivity symptoms outnumber the impulsivity ones. As you may recall, there are only three impulsivity symptoms and six hyperactivity symptoms. It, it turns out that some of these

symptoms also overlap with other disorders. So for example, Oppositional Defiant Disorder children may also have a tendency to have trouble waiting their turn and get you know, but into conversations just because they want what they want when they want it. So again, the notion of hyperactivity and impulsivity both being in the same dimension, yet they are very different types of symptoms. Being on the go, being very hyper is not the same as being impulsive and having trouble controlling what you say and do. So, what's in store in the future? Well, in the next year we are going to have a new diagnostic and statistical manual, the DSM-V. It's scheduled to be released in May of 2013. And a number of changes are going to be present in ADHD diagnosis. For example, the age of onset criterion will be raised from 7 years of age to 12 years of age. There's also a plan to leave the 18 criteria unchanged, but they're going to be more contextualized symptoms that are going to be illustrative of different ages. So, we'll have criteria to help us figure out. What does it mean for an adolescent to be inattentive versus an adult versus a child? Now, because impulsivity was poorly covered in DSM-IV, there are going to be up to four new criteria added covering impulsivity. And the number of criteria needed to make the diagnosis in adolescents and adults is going to be revised. And so, what's going to happen is that instead of needing six criteria for one or from another dimension it's probably going to be something like four from two dimensions will be acceptable to allow for adults and adolescents to be diagnosed with ADHD. And finally, the exclusion of, of individuals with autism spectrum disorders or pervasive developmental disorders, that exclusion's going to be removed. And hence, people with autism spectrum will also be able to be diagnosed with ADHD in the DSM-V. We're now going to turn to the prevalence and epidemiology of ADHD.

To begin with, let's look at the worldwide prevalence of ADHD and what is, what's the data base from which we make estimates of the Worldwide prevalence. Well, first of all, beginning with the summary of all of the studies that we see reported in this paper, 102 studies form across the world show that the worldwide prevalence of ADHD is somewhat higher than 5%. If we look at North American studies, 32 out of those 102 studies, the number is closer to 6%. Notice, by the way, both of these have very small confidence intervals, meaning that most of the studies are pretty much in agreement with one another, and therefore, we think of these as being rather accurate estimates. If we turn to, for example, the nine studies in South America, you can see that there's a much higher prevalence of ADHD reported in these studies. But also notice that there's a much wider area that this, these estimates cover. Meaning, that the certainty of this estimate is less certain than in these other studies. If we look at Africa, a similar problem emerges the prevalence in Africa is estimated to be about 8% but there's a very wide range of estimates of, of results from these studies. So, to summarize the geographic studies, we can say that worldwide, it's about 5%, in North America it's about 6% and similarly slightly lower in Europe, slightly under 5%. Now, what about the diagnosis of ADHD is different age groups? Well, if we look at the studies, looking at children, there's about an estimate of about 7% to 8% of children have ADHD, whereas looking at adolescents, the number is closer to between 3% and 4%. Finally, if we look at the gender breakdown of the prevalence of ADHD, it's clear that boys have a much higher prevalence than girls in these studies. The estimate across the world of, of, of the incidence of ADHD in boys is about 10%, give or take one or 2%, that's what the, these bar, these bars indicate. And among girls, it's about 4%. This is taken from a very wonderful paper in the American Journal of Psychiatry from 2007. Turning to the United States now and looking at some more recent studies, the prevalence we estimate in the US of ADHD

between, in 8 to 15 year olds is about 8.7%. Now, it turns out though, that only about a third of these children with ADHD have been treated consistently in the past year. If we turn to 18 to 44 year olds, the current estimate is that 4.4% of adults in the United States meet criteria for ADHD. Unfortunately, the treated prevalence is much lower in this group. In the last 12 months, only about 11% of adults with ADHD have received any treatment. So, we really have some treatment challenges ahead of us given the rates of the ADHD prevalence in different age groups in the United States. So, let me summarize what we know from all of the studies that I've mentioned. First of all, we estimate that about 9% of children, 7% of adolescents, and 4 and 1 half percent of adults in the United States suffer from ADHD. The male to female ratio of ADHD changes depending on the age. So, it's 6 to 1 in children, it's about 3 to 1 in adolescents. And it's closer to 1 to 1 in adults. These, these rates of ADHD are equivalent across all levels of IQ, and all levels of socioeconomic status. It really doesn't matter how bright you are or how well off you are, or how poor you are, the prevalence of ADHD is pretty much the same along all of those demographic features. We're going to talk a little more next time, next week on family genetics. But it looks like about 75% of the numbers of, of children with ADHD, 75% of that rate is due to genetics. And finally, the inheritance is not specific to the subtype of ADHD. So, inattentive ADHD is transmitted at the same rate as hyperactive, impulsive, or combined type ADHD. I'd like to turn now to real stories of people with ADHD. I'd like to call this the many faces of ADHD. And I'm going to describe to you a number of cases that have come through in my practice, that really show the different ways in which ADHD affects people throughout the lifespan. The names of these patients have been changed. But, you'll understand that, that's to

protect them from being identified. Let's start with first case, Tornado Tommy. Tornado Tommy is a 6 year old in 1st Grade. He has trouble focusing, can't sustain attention mostly in school, he's always looking around, he's never looking straight ahead at the teacher. He's squirmy in his seat. He's restless and fidgety, and he's always on the go. In fact, no one ever see him sit still for more than a minute. Hence, his nickname, Tornado Tommy. He talks all the time loudly and he interrupts everyone's conversation, and he just cannot wait his turn. Do you know anybody like Tornado Tommy? I can remember somebody like him when I was in first grade, and this happens to be one of the most common presentations of combined type of ADHD in a young child. Next, let's talk about Spacy Steve. Spacy Steve is 8 years old and he's in 3rd Grade. What does Spacy Steve look like? Well, he doesn't really listen. He's always in his own world, he's always kind of looking away and looking around, happy go lucky guy, but he's extremely forgetful. In fact, he never ever remembers what people tell him. He's always dawdling, he's trouble getting started with things. Both his parents and teachers say the same thing, it takes forever for Spacy Steve forever to get things done. He's not making much of an effort in his schoolwork or his homework, and he really has terrible organizational skills. When you open up his book, bag, things are a total mess. And then, even more frustrating for him and his teaches and his parents is that, he might even get his homework done at home with a lot of prompting from his parents. And then, he goes to school and he forgets to turn in the assignments and he gets zeros. Okay, so this is Spacy Steve. Spacy Steve, we could say is a classic child with a predominantly inattentive type of ADHD. Now, let me tell you a little bit about Ornery Arnold. Ornery Arnold is 10 years old, and he's

in 5th Grade. And he has really dissimilar to Tornado Tommy, he can't sit still. He can't, he fidgets all the time. And he can't focus either, and he can't really keep his attention on his schoolwork. He is always looking around and trying to fool around, making paper airplanes and, and, and, and trying to get to his, you know, his buddies and send them notes . But, in addition to his trouble with focusing and with hyperactivity, he's very argumentative. In fact, he's always saying, no, and I don't want to. And he just always challenges the rules. In fact, he gets on peoples nerves quite a lot. Okay, because he's so negative, he hates school. He thinks it's a total waste of time. In fact, he thinks he's in prison. When he, you ask him, how's school going? He goes, I feel like I'm in prison. And finally, he he doesn't like doing his homework. As you might imagine, he keeps putting it off and putting it off, procrastinating. And sometimes, he never even gets to it at all. but if he does get to it, he doesn't started 'til very late at night. So, Ornery Arnold has ADHD symptoms, but he's got even more than just ADHD. He's got a lot of oppositional features as well. he probably meets criteria for something more than just ADHD and he'd be a classic example of a boy who's beginning to show the signs of Oppositional Defying Disorder as well as ADHD. Now, let me introduce you to Babbling Brooke. Babbling Brooke is a very sweet 12 year old girl in 7th Grade. I mean, she's high energy, fun loving. Kind of life of the party. Very sociable. Everybody loves her, okay? The problem is that she's also such a chatter box that she really can't stop talking even when she needs to stop talking, okay? teachers are always telling her, come on, Brooke. You know, zip it. And Brooke can't seem to zip it for very long. and she's just like I said always, always

trying to find out what's going on with everybody. She's got to see who's doing what. And any time there's a little bit of a noise or anything going on outside the classroom, she's got to get up and look. So, she's very distractable. Brooke also loses things. I mean, she, she can't keep track of her eyeglasses, her clothes. She leaves her jacket in school, she leaves her assignment book in school. She'll leave her gym bag at, at, at gym an, an, and not have, have it when she needs it at home to wash her, her gym clothes. She's very, very disorganized. And in fact, when you open her book, bag, it's a complete mess. Papers all over, she has folders but papers aren't in the folders. And as you can imagine, Babbling Brooke isn't bent on doing her homework either. She'd rather start texting her friends or getting online and instant messaging and that's a problem because she's not getting to her homework. Now, let me tell you about Absentminded Anna. Absentminded Anna is 16 years old. She is in 11th Grade and she is an adolescent with some of the signs of ADHD. She also can't focus, she's very distractable, she's also restless and fidgety. And she's always on the go and never sits still. But the other problem for Anna is that, she's not just life of the party, she talks too loud and interrupts people, and can't wait her turn. So, she's seen by other girls as a bit of a, of a undesirable person. They don't like her sitting at their lunch table and they're not inviting her to their activities. So, Absentminded Anna is not just absentminded, she also has trouble figuring out social cues and really fitting in with her friends. Okay, this is another feature of ADHD that oftentimes in high school becomes a serious problem for, for girls. Especially because if they're not fitting in socially they will be the, eventually can become outcasts and may need some extra help. Now, let me tell you about Dizzy David. Now, Dizzy David is 20 years old, and

he's a junior in college, okay? And he comes in, and he's really, really upset because he can't read more than five minutes. He's got a very short attention span, and he's very distractable. When he's sitting in class, his mind just cannot stay on what the lecturer is saying. and if he tries to write notes, then he really loses track of what is being said. he says that if he, mind wanders off for a couple of minutes, by the time it comes back to what's going on, he's lost. He's just totally lost. The other problem that David reports is that he has trouble getting his stuff together. He, he just can't keep track of all of his things, and he can't manage his time very well either. He's always turning assignments in late he's missing scheduled appointments with friends, or, you know, even, even bailed out on a date with somebody he liked because he forgot when he was suppose to meet up with her. He also makes careless mistakes, especially on exams, and by now he's come in because he's not doing well in school. But he admits that he's losing his motivation to study. In fact, he's losing his motivation to even stay in school. He's not even sure he wants to finish college anymore. So, he's somebody that I would say not only has signs of ADHD in a college student, a young adult, but he's also beginning to loose motivation and maybe becoming a little depressed. can't tell from what I've told you so far, but that would be something that I'd be worried about the fact that he's loosing motivation and beginning to, to give up with the idea of doing well in school. Now, let me introduce you to Boisterous Bill. Boisterous Bill is a 30 year old unemployed married man. He comes because his wife has asked him to come for an appointment. And one of the things that she says about him is that he's irresponsible at home, and doesn't he get things done. She also complains that he doesn't, he doesn't have much consideration for other people. He's always interrupting, he's always

arguing he's also had trouble keeping jobs. Bill has changed jobs six times in the past four years. And even though he's a college grad, he just cannot keep a job. He's been fired for tardiness, for inefficiency, for trouble following directions, and occasionally even because he's gotten into arguments with his bosses. So, he really can't keep a job. And by now, he has low self-esteem and feels like a complete failure. He has ADHD symptoms of poor concentration and trouble completing tasks and restlessness. So, there's no question he has some of the symptoms of ADHD and meets the criteria for ADHD. But in addition, Boisterous Bill has trouble with social relationships and with keeping a job and he's starting to become depressed. He's feeling like a failure and he's giving up. And finally, let me introduce you to Lost Louise. Lost Louise is a 50 year old married woman. She's employed, works in an office. She's always had to work extra hard to get assignments done. And lately though, it's taking her even longer to finish things. When she's at work, her mind wanders all over the place. When she's sitting in a meeting, instead of listening to what's being said, she starts to space out. She cannot focus. Louise is very impatient also. She doesn't like to wait. She gets angry easily, very frustrated when there's a line at the bank or a line at the checkout line in the store. of great concern to Louise, and the reason she's coming in now for an evaluation is that she's starting to report that she can't remember the movies she's seen. She can't remember books she's read. And she can't even remember conversations she's had with important people in her life. So, this is beginning to really bother her a great deal. And finally, Louise gets lost easily and has always had a poor sense of direction. But this has gotten even more serious of

late and she's coming in because she really thinks she needs help for her difficult, difficulties with focusing and with remembering and with keeping track of things. So, I hope those cases help you to understand the many ways in which individuals with ADHD can be affected. And how difficult it is sometimes to live with this disorder, how impairing it can be. How much it can interfere with school success and with friendships, and with self-esteem and with keeping a job. We're not talking about ADHD in just children. We see it now as a life span disorder. Something that can affect you whatever stage of life you're in. And it is important then to understand about how impairments are affecting the individuals emotional state, and how well they're coping with the stresses in life. Because maybe helping their ADHD will allow them then to address those problems they're facing more effectively. Now, looking ahead for next week, what we're going to be talking about are the causal factors underlying ADHD. You've got a couple of readings. One is the NIMH ADHD Overview, and the other is from the CDC, Centers for Disease Control, the Data and Statistics summary. Please make sure you look these readings over before our next class. Thanks for sitting in, and look forward to talking with you again next week.