Published online April 1, 2008
PEDIATRICS Vol. 121 No. 4 April 2008, pp. e967-e974 (doi:10.1542/10.1542/peds.2007-1532)
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ARTICLE

Growth in Stimulant-naive Children With Attention-Deficit/Hyperactivity Disorder Using Cross-sectional and Longitudinal Approaches

Tomasz Hanc, MSc and Joachim Cieslik, PhD

Department of Human Biological Development, Institute of Anthropology, Faculty of Biology, Adam Mickiewicz University, Poznan, Poland


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The objective of this study was to investigate the growth of stimulant-naive children with attention-deficit/hyperactivity disorder in 3 aspects of development: level, trend, and structure of the process.

PATIENTS AND METHOD. The study sample included 53 individuals between the ages of 6 and 17 years (mean: 11.90). The average level of growth (z scores) in prepubertal, pubertal, and postpubertal stage of development and trend of the process were estimated on the basis of a comparison with growth charts. The prediction of adolescent growth spurt was conducted using the mathematical structural growth model of Jolioceur, Pontier, and Abidi.

RESULTS. Difference between boys with attention-deficit/hyperactivity and the norm was statistically significant in the prepubertal stage and for the average level of growth between the ages of 2 and 17 years. Distinct suppression of growth was found between the ages of 9 and 14. Analysis of development structure revealed an earlier onset of the adolescent growth spurt among boys (difference: 5 months) and a higher velocity of growth at this moment (difference: 0.33 cm/year) than expected values.

CONCLUSIONS. The application of both cross-sectional and longitudinal analyses clearly illustrated the higher level of growth of boys with attention-deficit/hyperactivity in the prepubertal stage, the suppression of growth on the turn of prepubertal and pubertal periods, and earlier occurrence of the spurt onset. Observed differences in the level and trend of growth as well as in the parameters of adolescent growth spurt are linked with disorder-related factors.

Key Words: ADHD • growth • longitudinal study

Abbreviations: ADHD—attention-deficit/hyperactivity disorder • JPA2—mathematical structural growth model of Jolioceur, Pontier, and Abidi • TO—onset of adolescent growth spurt • PHV—peak of adolescent growth spurt

Numerous studies have investigated abnormalities in the growth process related to attention-deficit/hyperactivity disorder (ADHD),1–6 but controversies remain concerning both the direction of deviation from the norm (do children with ADHD develop slower or faster than their healthy peers?) and the cause of that deviation. Most information about the development of children with ADHD is derived from studies that have investigated a link between the reduction of growth rates observed in these children and stimulant medication. The hypothesis that reduction of growth is an adverse effect of stimulant action was proposed by Safer et al,7 and a range of additional investigations have been conducted to verify this statement. Some of them have confirmed that reduction of growth1,8,9 is stimulant related, whereas others have failed to show any statistically significant delay of growth during the treatment.2,10,11

Spencer et al12,13 formulated the disorder-related delay hypothesis suggesting that observed growth deficit may be connected with ADHD, rather than stimulant medication. Children with ADHD could develop more slowly than the norm, and the consequence of this would be lower rates of body height in succeeding years than expected values and the achievement of biological maturity later than in their healthy peers. Swanson et al,3,8 however, reported dissimilar findings. In their studies, unmedicated children with ADHD were taller than medicated children and the average rates for the population. This may be related to overactivity of the DAT1 transporter, which results in a decrease of the dopamine level in the hypothalamus. A dopamine decrease in this part of the brain could interfere with the regulation of the hormone system and thereby lead to a higher rate of growth and greater body height than expected for age.14

Not much is known about the development of children with ADHD. This is in part the result of the numerous limitations of previous studies, most of which concentrated on the analysis of the effect of stimulants on body size. Some of the research displayed growth reduction, but it is not clear whether this reduction is connected with ADHD or is the result of stimulant medication. An additional factor that complicates any definite inference is the possibility that the slower rate of growth is a result of the accumulation of the effects of earlier medication. An estimation of development in children who have ADHD and are never medicated should be made to eliminate these doubts.

There is also little information regarding the growth process in all progressive stages of ontogenesis. If there are some abnormalities in the development of children with ADHD, then we do not know whether disruption occurs only within a short period of time or is a characteristic of the whole growth process until adult height is reached.

Most of the studies have compared the height of children with ADHD in successive moments of time with growth charts or a control group; therefore, it could be said that what has been surveyed is the level of development of children at successive points of growth. Such an approach has a cross-sectional character; however, multiple measures could also be used in a dynamic aspect of development analysis. This approach (which has a longitudinal character) may answer the question as to whether the growth of children with ADHD is characterized by a 1-directional trend of increase or decrease in the level of height in comparison with the norm in following points of research. A similar longitudinal approach was used by Swanson et al,2 who examined numerous points of height (up to 29 points) from each child to reveal the growth trend of medicated children with ADHD in comparison with the growth charts. Nevertheless, the study analyzed only a short period of growth (~1.5 years long), and normal growth of children with ADHD was not the aim of the investigation.

The structural aspect of the growth process in children with ADHD has never been investigated. Nothing is known about when such important development points as the onset and peak of the growth spurt occur. Developmental abnormalities could affect the level of growth as well as growth structure; therefore, investigations of the development of children with ADHD should take into account the growth spurt parameters such as duration and total increment of height during growth spurt.

Because knowledge regarding the typical growth pattern for children with ADHD is still insufficient, the growth process of children who were never medicated (with stimulants) was taken into consideration. The study has a longitudinal character, which includes the progressive stage of ontogenesis and concerns 3 aspects of development: level, trend, and structure of growth in children with ADHD.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Patient Group
Data were pooled from mental health clinics and psychological and pedagogical counseling centers located in the city of Poznan (~600000 citizens). Data concerning the frequency of ADHD among children in Poznan are not available. The prevalence of ADHD among children at younger school age in the city of Warsaw (similar stage of urbanization as in Poznan) estimated using the Revised Conners' Teacher Rating Scale was 4.4%.15 A total of 82 children were qualified for the study. The main criterion for inclusion was the diagnosis of ADHD confirmed by both child psychiatrists and psychologists according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision16 in the structured diagnostic interview. The diagnosis was established using the Diagnostic Interview for ADHD and Hyperkinetic Disorder. This tool estimates the intensity, frequency, and adequacy of symptomatic behaviors to developmental age and consists of 3 scales that measure attention deficit (9 items), impulsivity (4 items), and hyperactivity (5 items). The internal reliability of the scales—0.88 (attention deficit scale), 0.70 (impulsivity scale), and 0.72 (hyperactivity scale)—was estimated by the {alpha} Cronbach method. Conformance between diagnosis using the interview and Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) is 90% ({tau} Kendells correlation = 0.59).17 Each patient's parent or legal guardian signed a consent form, and each patient signed an assent form. The exclusion criteria were IQ < 80, epilepsy, fetal alcohol syndrome, organic brain dysfunctions, thyroid dysfunctions, and other diseases that could raise doubts about the diagnosis of ADHD or that could affect the growth process. Nineteen patients were excluded on the basis of these criteria. Overall, the study sample included 48 boys and 5 girls (10 children withdrew after initial consent) between the ages of 6 and 17 years (mean: 11.90; median: 11.37). The gender ratio (~10:1) was higher than in the research conducted by Poulton and Cowell1 on a similar number of children (n = 44, boys/girls; proportion: ~6:1). Owing to the limited representation of girls in the research, analysis was shown only for boys.

Procedure and Statistical Analyses
Height measures of the period between childbirth and the moment of the research were pooled from documentation of the periodic screening that is conducted for each child in Poland. Measures of actual growth were also made by individuals who are specialized in child development using a GPM anthropometer (precision of measurement is 1 mm). Metering was conducted according to the Martin-Saller standard technique.18 The mean of assessment points obtained for each child was 6 (up to 17).

Both cross-sectional and longitudinal approaches were used to categorize the data into age classes. In the cross-sectional approach, the obtained data were classed into a 0.5-year-long period (at the age interval: 1–3 years) and a 1-year-long period (at the age interval 3–17 years). The presented categories of age are the midpoints of class intervals (eg, measures among the 5.50–6.49 age class are treated as measures obtained at the age of 6 years).19 In the longitudinal approach, data were amended by individual growth curves, which were fitted to data by using a growth mathematical model. This method enabled the growth spurt parameters to be estimated.

For the purpose of cross-sectional analysis of development level, growth charts provided by the Institute of Anthropology of the University of Adam Mickiewicz20 were used to transform absolute units of measures (centimeters) into SD units (z scores). Differences between average values of body height in the sample and the norm for the population were estimated in 3 stages that were distinguished in the light of pubertal development. The onset of the pubertal stage was distinguished as the period in which the majority of individuals are likely to present the most important symptoms of puberty onset, such as volume of testes ~4 mL, pubic and axillar hair, and size of penis at the Tanner stage 2. Two years from the onset of puberty, in most boys, the main intensive second sex feature changes are likely to end.21,22 In consideration of this regularity, the following division seemed to be reasonable: prepubertal stage (boys between the ages of 2 and 12.5 years), pubertal stage (boys between the ages of 12.5 and 15 years), and postpubertal (boys older than 15 years).

Trend of development was assessed by using the forward stepwise regression method, which shows whether the linear directional positive or negative tendency of growth occurs in children with ADHD in comparison with the population norm. The values of the r Pearson statistic was an indicator of a directional growth trend existence. The average z scores in the subsequent years of life were used in the analysis.

The mathematical structural growth model of Jolioceur, Pontier, and Abidi (JPA2)23 was used to evaluate the structure of body height growth in the sample and to compare these data with previously estimated (using the same mathematical method) growth parameters of boys from Poznan.24 The JPA2 model assumes growth process continuity and describes it by a nonlinear curve fitted to empirical data by the method of Maximum a Posteriori. The model can be used from the age of 2 years to the achievement of adult stature and makes possible the illumination of growth spurt parameters, even when the longitudinal data are not complete (eg, when only measures from childhood are available). The model's equation is presented as follows:

Formula
where y is body height; t is age in years; a is adult body height; b1, b2, and b3 are positive quotients for time scale; and c1, c2, and c3 are positive indices for height measures.

In this study, the prediction of adolescent growth spurt parameters such as age, height, and velocity of growth at the onset of spurt (take-off [TO]); age, height, and velocity of growth at the peak of spurt (peak of height velocity [PHV]); and adult (final) body height and also increment of body height between TO and the moment of the achievement of adult height was made by using the JPA2 model. TO age was defined as the moment of the slowest velocity of growth, and PHV age was defined as the moment of the fastest velocity of growth.24 The age of achievement of 80% and 90% of adult height was also predicted.

Auxal software was used to assess the aforementioned structural parameters and main tendencies of growth with application of the JPA2 model. The JPA2 model construction and its implementations as well as application of the Auxal are described by Bock and colleagues.25,26

By applying the JPA2 model, a prediction was conducted for each child. Afterward, the average predicted parameters of growth spurt of children with ADHD were compared with the parameters of healthy children from Poznan, according to longitudinal studies on growth.24 Growth of children who were born in 1980 were observed from the fifth to the 19th years of life. A complete set of 28 measurements (intervals between measures were 6 months) were obtained for 181 boys and 176 girls. In the studies, the same standard method of metering was used as in this investigation. Differences in growth spurt between the sample and healthy children were evaluated by using the t test.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A higher growth level in the sample in comparison with the norm (0 in z height) was displayed for boys (Table 1) in the prepubertal stage (z height = 0.30) and in the postpubertal stage (z height = 0.40), but the outcome was statistically significant only for the first stage (t = 3.079, P = .002). The level of growth in the pubertal stage was similar to the norm (z height = 0.01, t = 0.069, P = .946). The average level of growth within the age group of 2 to 17 years was higher than 0 (z height = 0.28) and statistically significant (t = 3.164; P = .002). All values in particular years fit between z = –1 and z = 1, but the average values for the 3 quantified stages of development was higher than 0.


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  		TABLE 1 Differences From the Norm in the Average Height of Boys at Different Age Periods

 
The forward stepwise regression method on the average level of growth was used to determine whether a directional trend of development had occurred in the sample. The method did not show the existence of any distinct positive tendency of growth within the period of 2 and 17 years of life (r = 0.087, P = .741; Fig 1). A qualitative estimation of growth changes (Fig 1) suggested that a separate analysis of age periods 2 to 9, 9 to 14, and after 14 years would be more adequate. The method of regression displayed a strong positive tendency of growth (r = 0.657) in the period 2 to 9 years; however, the result was not statistically significant (P = .055; Fig 2). A very strong directional negative tendency (r = –0.934) was found within the period of 9 to 14 years (Fig 3). The level of growth decreased in this period from z = 1.00 to z = –0.2. This tendency has statistical significance (P = .006). The opposite trend was revealed in the period between the ages of 14 and 17 years. The tendency was strong and statistically significant (r = 0.964, P = .036; Fig 4).


Figure 1
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  		FIGURE 1 The average level of development (in z scores) and directional trend in growth in boys with ADHD.

 

Figure 2
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  		FIGURE 2 The directional positive trend of boys' growth (in z scores) between the ages of 2 and 9 years.

 

Figure 3
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  		FIGURE 3 The directional negative trend of boys' growth (in z scores) between the ages of 9 and 14 years.

 

Figure 4
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  		FIGURE 4 The directional positive trend of boys' growth (in z scores) after the age of 14 years.

 
The course of growth and its parameters for each individual were predicted using the JPA2 model on the obtained measures. The average values of parameters were compared with data from the sample of boys from the city of Poznan.24 The outcomes of this comparison are presented in Table 2. The comparison displayed a significant difference in the age of TO in boys between the sample and the population (P = .002). Growth spurt onset occurred ~5 months earlier (TO difference = 0.44) for boys with ADHD. There was also a velocity of growth at the point of TO higher in the sample (difference = 0.33 cm/year; P = .001). The total increment of height in spurt is significantly greater than in the comparison group by ~2.23 cm (P = .019). The rest of the spurt parameters did not differ significantly between the compared groups.


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  		TABLE 2 Comparison of Average Predicted Spurt Parameters Between Children With ADHD and the Sample of Boys From the Poznan Population

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
This study differs from previous investigations in its dynamic approach to development of children with ADHD. Distinct from previous studies,7,9,10,13,27 the period between the age of 2 years and the moment of adult height achievement was examined. The level of growth, the trend of the development, and the parameters of adolescent growth spurt omitted in previous research were assessed in this investigation. The method of prediction on the basis of the structural JPA2 model was used to assess the growth curve in children with ADHD as a disorder-dependent characteristic.

Study of the growth of 48 boys with ADHD showed the level of development in the prepubertal stage of growth and the average level of growth between the ages of 2 and 17 to be slightly higher than the norm. It was not possible to show a directional tendency of growth from among the analyzed phases of development (the direction of development was not constant); nevertheless, distinct suppression of growth was found among the age group of 9 to 14 years, although the height of boys with ADHD remained between the normal values for age (–1 < z > 1) throughout the entire investigated period of life.

A group of children who had never been medicated with stimulants were examined in the research; therefore, we were able to reveal the effects of ADHD-related factors on their development. The results are difficult to interpret according to previous studies. In the prepubertal stage (2–12.5 years), the cross-sectional analysis revealed a higher level of development than in the population. This is consistent with the findings of Swanson et al,3 which showed children with ADHD as having higher than expected values of height at the age of 5 years and supports the disorder-related acceleration of growth hypothesis. Nevertheless, the longitudinal analysis of growth tendency revealed a distinct suppression of growth between the ages of 9 and 14, which was not observed in the Multimodal Treatment Study,8 in which the children were taller at the baseline (age ~8.5) and displayed significantly increased growth during the subsequent several years compared with norms. This result is instead more consistent with the investigation of Spencer et al,12 which indicated suppression of growth in early puberty (Tanner stages 2 and 3) but not in prepubertal and postpubertal phases. It seems to support the hypothesis of disorder-related delay of growth. Current findings make it reasonable to think that suppression of growth observed in children with ADHD between the ages of 9 and 14 years is typical for their trajectory of development and does not affect adult height. Nevertheless, the comparison of development in untreated children with those who had been treated with stimulants8 suggests that precaution is necessary, and growth monitoring of children during treatment is recommended.

The achievement of a larger body height in prepubertal children with ADHD may be linked to a dopamine deficit in the hypothalamus, which is the effect of dopamine transporter overactivity.3,14 The hypothalamus controls hormone regulation; therefore, it is possible that a dopamine deficit in some way alters the proportion of the secretion of liberins and statins, which results in a higher level of development and acceleration of growth. The level of height in the ADHD group as revealed in our results was significantly higher than 0 in the prepubertal stage and decreased to the average reference value from the age of 9 years. This pattern of growth is comparable to the decrease of hyperactivity/impulsivity symptom intensity observed in middle childhood and adolescence.28 The co-occurrence of these effects suggests that the dopamine deficit, which is linked with both symptoms of ADHD and the higher level of growth in boys with the disorder, appearing in childhood, is compensated in the pubertal stage of development throughout the maturation of the nervous system.

The hypothesis linking ADHD, growth disruptions, and abnormalities in hormonal regulation found no confirmation in the research of Bereket et al29 in which the level of growth hormone, insulin-like growth factor 1 (IGH-I), triiodothyronine, and thyroxine in stimulant-naive prepubertal-age children with newly diagnosed ADHD during 16 months of methylphenidate treatment was examined. The level of hormones measured before the phase of treatment, important for our deliberations, fit into the norm for age. Nevertheless, some other studies have revealed a link between ADHD and hormonal dysfunction, such as generalized resistance to thyroid hormone.30

Analysis of development structure revealed using the JPA2 model should be interpreted separately because of its predictive character. Boys with ADHD seem to start their adolescent growth spurt 5 months earlier and have at this moment a higher velocity of growth (difference = 0.33 cm/year) than values among previously examined boys from the population of Poznan.24 The predicted total increment of height in spurt is also greater (~2 cm) than in healthy children; however, this does not determine difference in predicted adult height, which is similar in both groups. These results are consistent with the outcomes of the level of development analysis that displayed higher than the average reference values in the prepubertal stage (2–12.5 years) and not significantly different from the average reference values in the pubertal and postpubertal stages. All of these findings suggest a longer but less intensive adolescent growth spurt among individuals with ADHD in comparison with the healthy boys from Poznan.24 Nevertheless, children who were born in 1980 were examined in the longitudinal growth study of Poznan, and in this study, in which the mean individual age was 11.90, the average year of birth should be 1995. There is a possibility that the revealed differences in spurt parameters (as well as in the level of growth between the sample and the population norm) might be an effect of a secular trend in growth; however, results of anthropologic analysis suggest that secular changes of body height in many developing countries have stopped (contrary to positive growth trend in body mass),31 although this remains controversial. An interesting study on the secular trend was conducted in Poland by Nowicki.32 Results from 6 investigations (from 1935, 1946, 1951, 1971, 1979, and 1991) in which the growth of children and adolescents had been monitored were compared in the study. The analysis revealed a decrease of height and weight between individuals measured in 1935 and 1946; a significant increase between individuals measured in 1946, 1951, and 1971; a slowdown of the secular trend between 1971 and 1979; and no statistically significant difference between individuals measured in 1979 and 1991. This result suggests that the secular trend ended in the 1990s. The same conclusion gave a comparison of 8 studies on growth conducted in Poznan between 1880 and 2000 of large samples of boys and girls aged between 3 and 18 years.33 In the most recent decades (1960–2000), a distinct secular trend was found between the 1960s and the 1980s. This tendency of growth decelerated between 1990 and 2000 and seems to have stopped in Poland. The results of this research (greater height of individuals as well as characteristics of growth spurt) therefore should be an effect of ADHD-linked factors, not secular changes.

The JPA2 model allowed the parameters of the adolescent growth spurt to be predicted. They suggested an acceleration in the maturation of boys with ADHD. The onset of their growth spurt occurred earlier than in previously examined boys from Poznan, although the velocity of growth in the subsequent years of the pubertal stage tended to slow, as was shown by the lack of statistically significant differences in age at the PHV and body height at this point of growth. Predicted adult height was also similar to the norm. This seems to offer evidence that the relation between ADHD and the higher level of hormones that regulate growth occurred in the prepubertal (2–12.5 years) but not in the pubertal stage of development.

Our findings should be taken into consideration in future studies on the effect of stimulants on growth, especially between the ages of 9 and 14 years (which seem to be related to the disorder-dependent suppression of growth of boys with ADHD) and when data are compared with growth charts or a healthy peer control group. It should be stated, for example, whether a delay of growth ascertained in the research is not the result of growth tendencies that are characteristic for children with ADHD in successive stages of development rather than related to medication.

There are, however, a few limitations of this investigation that should be mentioned. The sample was small and consisted of 48 boys and 5 girls. Children with ADHD diagnosis were qualified for the study, although the level of comorbidity (children with ADHD often have symptoms of other disorders, eg, conduct disorder, depression, anxiety) was not examined in the group. It is unknown whether a comorbid condition of individuals in the sample differed from children in previous studies. This factor was not controlled in this investigation. Neither was the severity of ADHD taken into consideration. The children who were not treated with drugs could have differed from those who were medicated for the intensity of their symptoms. It is possible that children in the sample had a lower level of ADHD severity than medicated children in previous studies. Nevertheless, parents in Poland, aside from the severity of their children's symptoms, still distrust pharmacologic treatment and prefer other therapeutic methods, such as behavioral training.

The body height measurements (from the stage of life before the investigation) were taken by different people (pediatricians, school nurses); therefore, these data may have been affected by errors of estimation. The varying numbers of measurements disposed for each child (average 6 measurements per person) may also affect our results.

Also worth noting is that the results of the spurt parameters analysis on the basis of the prediction made using the JPA2 model should be interpreted appropriately. The age of children in the sample was an average of 12 years. The greater number of individuals were examined before and while undergoing the growth spurt; therefore, the observed parameters of adolescent growth spurt are a prognosis of the successive development of children with ADHD, based partly on data available for each individual and partly on the growth curve fitted to collected measurements using the parameters of a mathematical model.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The cross-sectional analysis revealed a higher, although still consistent with the norm, average level of development of boys with ADHD between the ages of 2 and 17 years. As was shown in the separate analysis of prepubertal, pubertal, and postpubertal stages, the major impact of this result was that boys had a significantly greater height in the first distinguished phase. Differences from the norm in subsequent stages did not reach statistical significance, which is consistent with the same predicted adult stature as in healthy children. The longitudinal analysis of growth trend revealed distinct growth suppression between the period of 9 to 14 years, which is not an effect of medical treatment and rather related to ADHD itself.

The prediction of growth spurt parameters conducted using mathematical modeling on longitudinal data displayed the earlier onset of adolescent growth spurt and a larger total increment of height in growth spurt among boys with ADHD in comparison with previously examined boys from the same part of Poland. The revealed differences are linked with the disorder factor, but this relation requires extensive investigation.

We have presented the preliminary results of a study of growth of children with ADHD. The impact of many of the factors that could modify the growth curve of these children was not shown. Nevertheless, in the near future, we will be able to present a more complete view of development of children with ADHD on the basis of a larger sample and a multivariate analysis of biological, social, and psychological influences on their growth, which has been never attempted before.


   ACKNOWLEDGMENTS
 
We thank Aldona Paprzycka and Anita Gürtler for contributions to the recruitment part of this study.


   FOOTNOTES
 
Accepted Sep 27, 2007.

Address correspondence to Tomasz Hanc, MSc, Department of Human Biological Development, Adam Mickiewicz University, Umultowska 89, 61-614 Poznan, Poland. E-mail: tomekh{at}amu.edu.pl

The authors have indicated they have no financial relationships relevant to this article to disclose.


What's Known on This Subject

Growth of children with ADHD could differ from the norm. There are three conflicting hypotheses in this field: children with ADHD grow slower, which is related with the disorder; growth suppression in this group is an adverse effect of stimulant action; children with ADHD grow faster than the norm if they are not treated with stimulants.

 


What This Study Adds

This study investigates growth in children with ADHD who have never been treated with stimulants. Three aspects of development are concerned: level, trend, and structure of growth in children with ADHD.

 


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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