text: When children with attention-deficit/hyperactivity disorder become adults. (Featured CME Topic: Pediatrics).HISTORICALLY, ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD Attention-Deficit/Hyperactivity Disorder (ADHD) Definition Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder characterized by distractibility, hyperactivity, impulsive behaviors, and the inability to remain focused on tasks or ) has been viewed as a disorder confined primarily to pediatric patients, with only a small percentage persisting into adulthood. (1) Recently, it has been reported that up to 50% of children with ADHD will continue to have manifestations of this disorder as adults. (2) The sex disparity seen in childhood is much less pronounced than in adults; while the male-to-female ratio of ADHD in childhood is as high as 10:1, the ratio may only be 2:1 in the adult population. (3) Primary care physicians who care for adults must be prepared to assume care of patients previously diagnosed with ADHD as children and to make the diagnosis in adults in whom it has not previously been diagnosed. DIAGNOSIS AND TREATMENT OF ADHD IN CHILDREN AND ADOLESCENTS There are not standard, uniform criteria for diagnosis and management of the child or adolescent with ADUD. The Diagnostic and Statistical Manual of Mental Disorders Diagnostic and Statistical Manual of Mental Disorders /Di·ag·nos·tic and Sta·tis·ti·cal Man·u·al of Men·tal Dis·or·ders/ (DSM) a categorical system of classification of mental disorders, published by the American Psychiatric Association, that delineates objective , Fourth Edition (DSM-IV DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States. ) defines 3 subtypes of attention-deficit/hyperactivity disorder: combined, predominant inattentive in·at·ten·tive adj. Exhibiting a lack of attention; not attentive. inat·ten , and predominant hyperactive/impulsive, (4) based upon the predominant symptom pattern over the previous 6 months. Symptoms must be present before age 7 years and there must be some documented impairment of social, academic, or occupational function. More pervasive developmental disorders Pervasive Developmental Disorders Definition Pervasive developmental disorders include five different conditions: Asperger's syndrome, autistic disorder, childhood disintegrative disorder (CDD), pervasive developmental disorder not otherwise specified , schizophrenia, and other psychotic disorders must be excluded. The Classification of Child and Adolescent Mental Diagnosis in Primary Care, Child and Adolescent (DSM-PC) defines ADHD more broadly as a developmental variation, problem, and disorder, (5) with ADHD variation and problem being of lesser severity than the ADHD disorder, which uses DSM-IV criteria. The American Academy of Child and Adolescent Psychiatry A branch of psychiatry that specialises in work with children, teenagers, and their families. History An important antecedent to the specialty of child psychiatry was the social recognition of childhood as a special phase of life with its own developmental stages, starting with , (6,7) the American Academ y of Pediatrics, (8,9) and the National Institutes of Health (10) have written practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. for diagnosis and treatment of the child/adolescent with ADHD, and recommend evaluations which include: 1) parent/child interviews, 2) school assessments, 3) a comprehensive physical examination, 4) speech/language evaluations, and 5) occupational/recreational testings. These guidelines for the child with ADHD do not apply to young people with mental retardation mental retardation, below average level of intellectual functioning, usually defined by an IQ of below 70 to 75, combined with limitations in the skills necessary for daily living. , pervasive developmental disorders, moderate to severe sensory deficits, or those taking drug therapies that affect behavior. Treatment recommendations include medication, particularly stimulants, as well as psychosocial and educational interventions. (6,7,9) Caution is necessary in the use of stimulant medications because they are controlled substances which may be abused by family and patients, particularly adolescents or their peers. (7,8,10) Psychosocial interventions include parent behavior-modification training, support groups, family psychotherapy, social skills training, individual therapy, and day treatment programs. Educational interventions include token economies, time-out procedures, response-cost programs, and homework notebooks. (6) Combined modality treatment is generally recommended (ie, medication and psychosocial interventions). The efficacy of medications, mainly stimulants, in the treatment of ADHD symptoms for up to 14 months has been established. Similarly, the effect of psychosocial interventions on symptoms particularly related to ADHD comorbidity has been established for this time period. There have not bee n studies to demonstrate long-term efficacy of medication or behavioral interventions. Most research has been performed in structured, academic, clinical settings, but has not been demonstrated in clinical practice. Furthermore, the short-term and long-term improvement in ADHD symptoms, academic/occupational functioning, and social/mental health have not been shown to be sustained if medication and/or psychosocial educational interventions are stopped. (6,9,10) Some authors recommend that medications be prescribed based upon likely family compliance with psychosocial/educational recommendations and that drug holidays or definite plans to discontinue medication be formulated. (11,12) Behavioral counseling is also recommended in family setting. (13) The primary care physician should seek consultation if there are comorbid mental disorders, a developmental delay developmental delay n. A chronological delay in the appearance of normal developmental milestones achieved during infancy and early childhood, caused by organic, psychological, or environmental factors. , if the child is very young, or if there is not the expected response to given interventions. (14) DIAGNOSIS AND TREATMENT OF ADHD IN ADULTS The DSM-IV outlines the criteria necessary to make the diagnosis of ADHD in both children and adults. The diagnosis of adult ADHD is usually a difficult one to make, because it requires integration of a broad range of information in the absence of a definitive diagnostic tool. A large differential diagnosis differential diagnosis n. Determination of which one of two or more diseases with similar symptoms is the one from which the patient is suffering. Also called differentiation. and a high rate of comorbid conditions further complicate making this diagnosis. Attentiondeficit/hyperactivity disorder in an adult can only be diagnosed by DSM-IV criteria if the individual had ADHD symptoms as a child. If no diagnosis of ADHD was made in childhood, a retrospective determination of ADHD symptoms is required to make the diagnosis in adulthood. By strict adherence to the requirements of the DSM-IV, symptoms would have had to be present before the age of 7 years, although this specific age-of-onset criterion has been questioned. (2) In order to establish a retrospective diagnosis of ADHD, obtaining a thorough history is paramount. The history should include parental reports of ADHD symptoms in a variety of settings, objective accounts of school conduct and performance, and previous psychiatric therapies. (15,6) The triad of inattention in·at·ten·tion n. Lack of attention, notice, or regard. Noun 1. inattention - lack of attention basic cognitive process - cognitive processes involved in obtaining and storing knowledge , impulsivity, and hyperactivity symptoms are usually not present in adults with ADHD. Inattention is the most prominent symptom, seen in over 90% of adults with this disorder, (3) while hyperactivity is less often a problem and is possibly the reason adult ADHD initially went unrecognized. The effects of adult ADHD can be strikingly similar to those seen in children (eg, school failure, occupational failure, legal problems, difficulty with interpersonal relationships). Bresnahan et al (17) compared electroenceophalogram (EEG EEG: see electroencephalography. ) findings in children, adolescents, and adults diagnosed with ADHD, and found that the changing symptoms in these age groups correlated with subtle differences in their EEGs. There are several self-reporting tools used to screen for adult ADHD. Examples of these scales include the Wender Utah Rating Scale and the Copeland Symptom Checklist Symptom Checklist SCL-90R Psychology An instrument that assess 9 domains of psychiatric Sx–anxiety, depression, hostility, interpersonal sensitivity, obsessive-compulsiveness, paranoid ideation, phobic anxiety, pychoticism, somatization for Adult Attention Deficit Disorders attention deficit (hyperactivity) disorder (ADD or ADHD) formerly hyperactivity Behavioral syndrome in children, whose major symptoms are inattention and distractibility, restlessness, inability to sit still, and difficulty concentrating on one thing for any . Although use of self-reporting scales in adults has been shown to accurately describe ADHD symptomatology symptomatology /symp·to·ma·tol·o·gy/ (simp?to-mah-tol´ah-je) 1. the branch of medicine dealing with symptoms. 2. the combined symptoms of a disease. symp·to·ma·tol·o·gy n. , (18) the scales lack specificity. Additional measures are needed to assist in making the diagnosis of adult ADHD. (19,20) Rating scales may aid in monitoring the symptoms and course of the disease. The differential diagnosis of ADHD must exclude comorbid psychiatric conditions, such as major depression and substance abuse. Medical conditions in the differential diagnosis include hyperthyroidism hyperthyroidism: see thyroid gland. , hepatic disease, intoxications, and sleep-disordered breathing. (21) A thorough medical evaluation, including a thyroid panel, serum lead level, and urine drug screen, are indicated to rule out these disorders. No specific neuropsychologic testing is recommended for the diagnosis of ADHD, but it may be useful when the diagnosis is uncertain. The testing should be individualized in·di·vid·u·al·ize tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es 1. To give individuality to. 2. To consider or treat individually; particularize. 3. for each patient. (20) Personality traits have been associated with adults who have ADHD, (22) particularly an increased incidence of mild histrionic histrionic /his·tri·on·ic/ (his?tre-on´ik) excessively dramatic or emotional, as in histrionic personality disorder; see under personality. traits. Adults with ADHD and comorbid disorders demonstrated avoidant and dependent personality styles. When oppositional defiant disorder Oppositional Defiant Disorder Definition Oppositional defiant disorder (ODD) is defined by the Diagnostic and Statistical Manual of Mental Disorders occurs with ADHD, avoidant, narcissistic nar·cis·sism also nar·cism n. 1. Excessive love or admiration of oneself. See Synonyms at conceit. 2. A psychological condition characterized by self-preoccupation, lack of empathy, and unconscious deficits in , antisocial antisocial /an·ti·so·cial/ (-so´sh'l) 1. denoting behavior that violates the rights of others, societal mores, or the law. 2. denoting the specific personality traits seen in antisocial personality disorder. , aggressive-sadistic, and negativistic traits are often found. Adults with ADHD frequently have comorbid disorders, including substance abuse, depression, oppositional defiant disorder, and panic disorder Panic Disorder Definition A panic attack is a sudden, intense experience of fear coupled with an overwhelming feeling of danger, accompanied by physical symptoms of anxiety, such as a pounding heart, sweating, and rapid breathing. . Whether incidence of substance abuse is increased in adults with ADHD is unclear. Biederman et al (23,24) have published several articles implicating im·pli·cate tr.v. im·pli·cat·ed, im·pli·cat·ing, im·pli·cates 1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot. 2. ADHD as a risk factor, but Lynskey et al (25) question this association without a concomitant diagnosis of a conduct disorder Conduct Disorder Definition Conduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence. Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of . Treatment for adults includes medication and psychosocial interventions. Medication continues to be the mainstay of treatment in adults because of its demonstrated short-term benefits; however, medication has not been shown to improve the long-term outcome of ADHD. (26) Stimulant medications, such as methyiphenidate hydrochloride hydrochloride /hy·dro·chlo·ride/ (-klor´id) a salt of hydrochloric acid. hy·dro·chlo·ride n. A compound resulting from the reaction of hydrochloric acid with an organic base. , amphetamine amphetamine (ămfĕt`əmēn), any one of a group of drugs that are powerful central nervous system stimulants. Amphetamines have stimulating effects opposite to the effects of depressants such as alcohol, narcotics, and barbiturates. , and pemoline pemoline /pem·o·line/ (pem´ah-len) a central nervous system stimulant used in the treatment of attention-deficit. pem·o·line n. , have been the most popular. Weight-adjusted doses of methylphenidate hydrochloride methylphenidate hydrochloride Concerta, Daytrana, Equasym (UK), Metadate CD, Metadate ER, Methylin, Methylin ER, PHL-Methylphenidate (CA), PMS-Methylphenidate (CA), Riphenidate (CA), Ritalin, Ritalin LA, Ritalin-SR Pharmacologic class: had a 74% efficacy in adults, similar to what has been found in children. (27) Treatment with desipramine hydrochloride de·sip·ra·mine hydrochloride n. A tricyclic antidepressant that selectively blocks reuptake of norepinephrine. desipramine hydrochloride Norpramin Pharmacologic class: , a tricyclic antidepressant tri·cy·clic antidepressant n. Any of a class of antidepressants, such as amitriptyline, that are structurally related to the phenothiazine antipsychotics. , showed a similar efficacy of 68%, and may be a good alternative for adults who cannot tolerate or have a contraindication contraindication /con·tra·in·di·ca·tion/ (-in?di-ka´shun) any condition which renders a particular line of treatment improper or undesirable. con·tra·in·di·ca·tion n. to stimulants. (28,29) Buproprion hydrochloride therapy showed good efficacy in adults with ADHD in a randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. , double-blind, placebo-controlled trial. (30) The role of psychosocial interventions in adults is less clearly defined. The main form of therapy used in adults with ADHD is cognitive behavioral therapy cognitive behavioral therapy n. A highly structured psychotherapeutic method used to alter distorted attitudes and problem behavior by identifying and replacing negative inaccurate thoughts and changing the rewards for behaviors. , which includes problem-solving strategies, self-monitoring, self-reinforcement, and skills training. The goal of these therapies is to improve self-control. Psychosocial interventions, like medication, have not been shown to improve the long-term outcome of ADHD. (26) Hechtman (31) describes 3 outcomes of adult ADHD. Thirty percent of adults with this disorder function well and are not different from adults who do not have ADHD. The majority of adults with ADHD continue to have problems with concentration, impulsivity, and social interactions, resulting in educational, occupational, and social problems. The third group consists of a minority (10%-15%) of adult ADHD patients with frequent hyperactivity who have concomitant significant psychiatric or antisocial symptoms. (31) Peer-controlled, prospective follow-up studies on ADHD in adolescents and adults confirmed the above findings. (32) TRANSITION OF CARE OF ADHD PATIENTS FROM PEDIATRICIANS TO PRIMARY PHYSICIANS WHO CARE FOR ADULTS There are 2 circumstances in which primary care physicians of adults may encounter a patient who presents with adult ADHD. The patient may have been previously diagnosed in his youth or never have been previously diagnosed but have the disorder. A primary care physician may also have cared for the pediatric patient and may continue care for that patient in adulthood. Diagnosing ADHD is challenging because of the large differential diagnosis, the many possible comorbidities, and the lack of a definitive diagnostic test. (4-6,8,10) Since the majority of children who are diagnosed with ADHD show no evidence of any mental disorder mental disorder Any illness with a psychological origin, manifested either in symptoms of emotional distress or in abnormal behaviour. Most mental disorders can be broadly classified as either psychoses or neuroses (see neurosis; psychosis). Psychoses (e.g. in adulthood, (32) those who continue to have the disorder are a select group. Some possible explanations are that an incorrect diagnosis of ADHD was made, (33) a comorbid diagnosis was missed or has subsequently occurred, treatment has been ineffective (possibly because of poor compliance), and/or the patient has a more complicated form of ADHD with persistent morbidity. The physician who assumes care of an adult with a previous diagnosis of ADHD should determine how the initial diagnosis was made. Careful review of the record is necessary to determine the presenting symptoms, the evaluators, physical examination findings, medication use, prior medical disorders, and family history. The background of the diagnostician(s) must also be determined. Results of diagnostic tests (particularly psychoeducational testing and speech and language testing) should be reviewed. Records should also be reviewed to determine what medications and psychosocial and educational interventions have been tried, and what impact the interventions had. A comprehensive medical and psychosocial history, as well as a complete physical examination, should be performed. An attempt should be made to obtain a medical history from a spouse or significant other, parents, other close relatives, teachers, employers, and/or friends. The updated assessment will likely take 2 or 3 visits to complete. Based upon the expertise of the primary care physician and the complexity of the case, consultation with a behavioral subspecialist should be considered. The primary care physician who is maintaining care of an adult with ADHD should also review how the diagnosis was made and examine previous treatment effects. An updated history, including sources other than the patient, should be taken and physical examination should be done. Medication and psychosocial interventions continue to be the treatment options in adult ADHD. Unfortunately, no intervention has been shown to improve the long-term outcome of ADHD. (7,9,10) Stimulant medications, particularly methylphenidate hydrochloride and amphetamine, the primary treatment for adult ADHD, are controlled substances. Other kinds of medications, such as desipramine hydrochloride and buproprion hydrochloride, have been found to provide effective treatment in adults. (28-30) Prescribing these medications eliminates the possibility of stimulant abuse. Referral of adults for psychosocial interventions not offered by the primary care physician should be made. Consultation with or referral to a behavioral specialist should occur if increasing doses of stimulant medications are required, if multiple psychoactive drugs Psychoactive drugs Any drug that affects the mind or behavior. There are five main classes of psychoactive drugs: opiates and opioids (e.g. heroin and methadone); stimulants (e.g. cocaine, nicotine), depressants (e.g. are needed, or if social, academic, or occupational functioning does not improve with optimization of pharmacologic and psychosocial interventions. DISCUSSION Although ADHD is the mental health disorder in the DSM-IV that has been most extensively studied in children, it continues to generate a great deal of controversy associated with diagnosis and treatment. (10,34) This is true, in parts, because the number of symptoms required by the diagnostic criteria for ADHD has never been empirically validated, generally being defined as "often", which makes judgment of the existence of symptoms subjective. (8) Treatment with stimulant medication is controversial because it has long been known that clinical response is the same in normal children and children with the ADHD diagnosis. (35) It is also known that the diagnosis and treatment of ADHD in clinical practice may not reflect what is done in optimal, research-type settings. (36) A recent commentary in a supplement to Developmental and Behavioral Pediatrics highlights the controversy surrounding the diagnosis and treatment of ADHD in early childhood. (37) An increase of more than 700% in the production of methyiphenidate hydrochloride and of more than 2,500% in amphetamine production occurred in the United States between 1991 and 2000. Although guidelines for diagnosis and treatment of ADHD are available, it has been found that the use of methylphenidate hydrochloride (Ritalin) in primary care and community medicine is inconsistently linked to the ADHD diagnosis. The use of methylphenidate hydrochloride, which has escalated in the last decade, varies widely in different communities throughout the United States. Government policy may have affected the diagnosis and treatment of ADHD; the Individuals With Disabilities Act in 1991 made ADHD a covered diagnosis for education disability services, which correlated with the increase in both ADHD diagnosis and stimulant use. (37) The National Institute of Mental Health The National Institute of Mental Health (NIMH) is part of the federal government of the United States and the largest research organization in the world specializing in mental illness. multimodal Two or more modes of operation. The term is used to refer to a myriad of functions and conditions in which two or more different methods, processes or forms of delivery are used. On the Web, it refers to asking for something one way and receiving the answer another; for example requesting treatment study for ADHD has been touted as the gold standard for research in mental health disorders of children. The detailed analysis of this study by Pelham (38) raises questions about the design of this research and the validity of the authors' conclusion that medication alone is the preferred treatment for childhood ADHD. The multimodal treatment study had 4 treatment groups: 1) medication alone (38 mg/day of methylphenidate hydrochloride); 2) intensive behavioral treatment (including parent training, a summer treatment program, and a school intervention with a short-term classroom aide); 3) a combination of behavioral interventions with medication: and 4) a community control group that received a mean prescribed dose of 23 mg/clay of methylphenidate hydrochloride. Nineteen outcome measures were assessed over a 14-month period. It is noteworthy that the intensive behavioral interventions were reduced 4 to 5 months before the end of this period, while me dication doses remained at maximally tolerable levels throughout the study. (38) All 4 treatment groups showed striking improvement from the time of baseline measurements to completion of the study 14 months later. Behavioral treatment was as effective as medication alone on 16 of 19 outcome measures, and was generally equivalent to community treatments. The results of combined treatment did not differ appreciably from those of medication management, but were generally superior to those of behavioral treatment. Both medication management and combined treatment were generally superior to community treatments. Although other authors have concluded that medication alone is the preferred treatment for ADHD, Pelham concludes that combined treatment, which "normalized" a higher rate of children than either medication or behavioral intervention alone, is the preferred treatment. He also notes that behavioral improvement is sustained after interventions are withdrawn, whereas medication effects stop. The persistence of improved symptoms may be one of the reasons that parents prefer the inclusion of behavioral treatment in the care of their children, rather than the use of medication alone. (38) The fact that stimulants are controlled substances with known abuse potential results in middle and high school students being approached to sell or trade their ADHD medications. (39) Although research has indicated that children with ADHD treated with stimulant medication are less likely to abuse drugs than those who were not medicated medicated /med·i·cat·ed/ (med´i-kat?id) imbued with a medicinal substance. medicated contains a medicinal substance. , (24) these patients are nevertheless using a controlled substance with the potential for abuse. The primary use of a controlled substance to treat ADHD raises philosophic questions, especially in children who may require lifelong treatment, which may explain why this disorder continues to generate heated controversy. CONCLUSION The diagnosis and treatment of ADHD are very complex and controversial. Although there is consensus that this disorder exists, professionals continue to struggle to make an accurate diagnosis and prescribe treatments with established long-term efficacy. Thoughtful, comprehensive care, both diagnostically and therapeutically, needs to be provided for patients who present with ADHD symptoms. A thorough reassessment should be done when a patient previously diagnosed with ADHD transitions from pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. to adult primary care. Physicians must vigilantly monitor the evolving research related to this complex disorder to ensure that they continue to provide the quality of care that children and adults with ADHD symptoms need. Acknowledgments. We thank Linda Adams, CPS, for her expert assistance in the preparation of this manuscript, and Michele Stanek, MHS (1) (Message Handling Service) An earlier messaging system from Novell that supported multiple operating systems and other messaging protocols, including SMTP, SNADS and X.400. It used the SMF-71 messaging format. , for providing her expert advice identifying references and resources. Resources Research Clinical Trials Involving ADHD. Details and contact information for current studies can be obtained from the National Institute of Mental Health Web site (http://www.nimh.nih.gov) and from the National Institutes of Health clinical trials Web site (http://www.clinicaltrials.gov). * A Behavioral and Functional Neuroimaging Study of Inhibitory Motor Control: This is an outpatient 2-day evaluation study comparing behavior on a computer game between children (ages 7-10) with and without ADHD. * Methylphenidate methylphenidate /meth·yl·phen·i·date/ (meth?il-fen´i-dat) a central stimulant, used in the form of the hydrochloride salt in the treatment of attention-deficit in children and narcolepsy. Efficacy and Safety in ADHD Preschoolers: This is an outpatient treatment study of methylphenidate hydrochloride to examine its safety and efficacy in treating ADHD in preschool and school-age children (aged 3-5 years, 6-8 years). * Brain Imaging of Childhood Onset Psychiatric Disorders, Endocrine Disorders and Healthy Controls: This is an outpatient evaluation study of identical twins identical twins pl.n. Twins derived from the same fertilized ovum that at an early stage of development becomes separated into independently growing cell aggregations, giving rise to two individuals of the same sex, identical genetic makeup, and , aged 6-16 years, where only one twin has the ADHD diagnosis. Magnetic resonance imaging magnetic resonance imaging (MRI), noninvasive diagnostic technique that uses nuclear magnetic resonance to produce cross-sectional images of organs and other internal body structures. (MRI 1. (application) MRI - Magnetic Resonance Imaging. 2. MRI - Measurement Requirements and Interface. ), computerized tests, and psychoeducational batteries will be used to study the twins. * Genetic Aspects of Neurologic and Psychiatric Disorders: The purpose of this observational study is to explore the genetic causes of specific neurologic and psychiatric disorders, particularly mental retardation, childhood-onset schizophrenia, ADHD, atypical psychosis of childhood, and bipolar affective disorder affective disorder Mental disorder characterized by dramatic changes or extremes of mood. Affective disorders may include manic or depressive episodes less severe than those of bipolar disorder, such as anxiety and depression. . Molecular genetic techniques will be used to identify the areas of chromosomes containing genes responsible for the development of these disorders. * Anatomic MRI Brain Imaging of White Matter in Children: This observational study will use MRI to examine connections between brain regions in children with and without learning/behavioral problems. The study will focus on twin pairs from 6 to 21 years of age, either with or without ADHD. * Cortical Correlates of Subtle Motor Signs in Children with Attention-Deficit/Hyperactivity Disorder and Healthy Controls--A Study Using Single and Paired Pulse Transcranial Magnetic Stimulation Transcranial magnetic stimulation A procedure used to treat patients with depression. Mentioned in: Magnetic Field Therapy transcranial magnetic stimulation, n (TMS TMS Transcranial Magnetic Stimulation (alternative medicine for depression) TMS Test Match Special (sports - cricket) TMS Texas Motor Speedway TMS Transportation Management System TMS Toyota Motor Sales ): This observational trial will use TMS to analyze the association of clinical abnormalities with any delay/abnormality in maturation of areas of the nervous system responsible for motor activity. * Biological Markers in Childhood Psychiatric Disorders: In this observational study, researchers will examine the anatomy of brain development to better understand the causes of ADHD. This study will further analyze a group of patients previously diagnosed with ADHD by giving them structured psychiatric interviews and neuropsychologic tests. They will have MRI of the brain repeated, as well as further clinical and genetic testing Genetic Testing Definition A genetic test examines the genetic information contained inside a person's cells, called DNA, to determine if that person has or will develop a certain disease or could pass a disease to his or her offspring. . * A Behavioral and Functional Neuroimaging Study of Inhibitory Motor Control: This observational study will examine the brain's control over a motor act, such as pushing a button. This will help to assess whether an inhibitory deficit exists in children with ADHD. * Multimodal Treatment Study of Children with ADHD: This continuation of the MTA (1) (Message Transfer Agent or Mail Transfer Agent) The store and forward part of a messaging system. See messaging system. (2) See M Technology Association. 1. (messaging) MTA - Message Transfer Agent. Study will track the persistence of intervention-related effects; test hypotheses regarding predictors, mediators, and moderators of long-term outcome in children with ADHD, and study patterns of risk/protective factors. This follow-up extends the study to 36, 60, and 84 months post-treatment. * Nutrient Intake in Children with Attention Deficit Hyperactivity Disorder attention deficit hyperactivity disorder (ADHD), formerly called hyperkinesis or minimal brain dysfunction, a chronic, neurologically based syndrome characterized by any or all of three types of behavior: hyperactivity, distractibility, and impulsivity. : This observational study will examine the nutrient intake of children with ADHD and study the occurrence of carbohydrate craving in these children. * Methylphenidate for Hyperactivity and Impulsiveness in Children and Adolescents with Pervasive Developmental Disorders: This interventional study will examine the efficacy and safety of methylphenidate hydrochloride for treating hyperactivity, impulsiveness, and distractibility in children/adolescents with pervasive developmental disorders (PDD). * Psychopharmacology psychopharmacology (sī'kōfär'məkŏl`əjē), in its broadest sense, the study of all pharmacological agents that affect mental and emotional functions. of Adolescents with Alcohol-use Disorder and ADHD: This interventional study will compare the effectiveness of buproprion hydrochloride versus placebo in the treatment of adolescents with ADHD and alcohol-use disorder. * A Treatment Study of Youth with Comorbid Attention Deficit Hyperactivity Disorder (ADHD) and Anxiety Disorder anxiety disorder n. Any of various psychiatric disorders in which anxiety is either the primary disturbance or is the result of confronting a feared situation or object. : This interventional study will gather information on the efficacy and safety of pharmacotherapy pharmacotherapy /phar·ma·co·ther·a·py/ (-ther´ah-pe) treatment of disease with medicines. phar·ma·co·ther·a·py n. Treatment of disease through the use of drugs. for children and adolescents (aged 6-17 years) with both ADHD and anxiety disorders Anxiety disorders A group of distinct psychiatric disorders characterized by marked emotional distress and social impairment, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. . Stimulant medication will be studied alone and in combination with a selective serotonin reuptake inhibitor selective serotonin reuptake inhibitor n. SSRI. Selective serotonin reuptake inhibitor (SSRI) A class of antidepressants that work by blocking the reabsorption of serotonin in the brain, raising the levels of . * Attention Deficit Disorder and Exposure to Lead: This observational study examines lead's possible contribution to ADHD by assessing the past lead exposure of children with and without ADHD. X-ray fluorescence spectroscopy will be used to assess bone lead levels. * Clonidine clonidine /clo·ni·dine/ (klo´ni-den) a centrally acting antihypertensive agent, used as the hydrochloride salt; also used in the prophylaxis of migraine and the treatment of dysmenorrhea, menopausal symptoms, opioid withdrawal, and in ADHD: This interventional study will evaluate the benefits and side effects Side effects Effects of a proposed project on other parts of the firm. of clonidine hydrochloride clonidine hydrochloride Warning - High-alert drug! Apo-Clonidine (CA), Catapres, Dixarit (CA), Duraclon, Novo-Clonidine (CA), Nu-Clonidine (CA) Pharmacologic class: and methylphenidate hydrochloride used alone and in combination in children with ADHD. Organizations * The National Institute of Mental Health has a link on its Web site for information for the public (http://www.nimh.nih.gov). This section has information on available books, informational materials, and fact sheets in English and Spanish. * The National Institute of Mental Health has a link on its Web site for information for practitioners (http://www.nimh.nih.gov). * Patient handouts on ADHD can be found in English and Spanish at http://www.familydoctor.org, a site sponsored by the American Academy of Family Physicians American Academy of Family Physicians, n.pr a national medical organization established in 1947 to promote the practice of family medicine. . * Attention Deficit Information Network (Ad-IN), 475 Hillsicle Aye, Needham, MA 02194. Telephone: (781) 455-9895. Web site: www.addinfonetwork.com * National Attention Deficit Disorder Association (ADDA), 1788 Second St, Suite 200, Highland Park, IL 60035. Telephone: (847) 432-ADDA (2332). Web site: http:// www.add.org * Children and Adults with Attention Deficit Disorders (CHADD CHADD Children and Adults with Attention-Deficit/Hyperactivity Disorder (Landover, MD, USA) CHADD Children with Attention Deficit Disorder CHADD Change of Address ), 8181 Professional P1, Suite 201, Landover, MD 20785. Telephone: (800) 233-4050, (301) 306-7070. Web site: http://www.chadd.org Books * Alfutis S: Inside Attention Deficit Disorder: A Collection of Thoughts and Feelings on ADD by an Adult Who has Been There. Toledo, Ohio, ADDult Support Network, 1991. Available from ADDult Support Network, 2620 Ivy Place, Toledo, 0H 43613. $16.00 * Barkley RA: Hyperactive Children: A Handbook for Diagnosis and Treatment. New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , Guilford Press, 1981 * Barkley RA: Defiant Children: A Clinician's Manual for Assessment and Parent Training. New York, Guilford Press, 2nd Ed, 1997 * Barkley RA: Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York, Guilford Press, 1998 * Barkley RA, Murphy KR: Attention Deficit/Hyperactivity Disorder Attention deficit/hyperactivity disorder A persistent pattern of inattention, hyperactivity and/or impulsiveness; the pattern is more frequent and severe than is typically observed in people at a similar level of development. : A Clinical Workbook New York, Guilford Press, 1998 * Goldberg R: Sit Down and Pay Attention: Coping with ADD Throughout the Life Cycle. Washington, DC, PIA pi·a n. The pia mater. pial adj. Press, 1991 * Weiss L, Hechtman L: Hyperactive Children Grown Up: ADHD in Children, Adolescents and Adults. New York, Guilford Press, 1993 * American Academy of Pediatrics The American Academy of Pediatrics ("AAP") is an organization of pediatricians, physicians trained to deal with the medical care of infants, children, and adolescents. Its motto is: "Dedicated to the Health of All Children. : The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Elk Grove Village Elk Grove Village, village (1990 pop. 33,429), Cook and Du Page counties, NE Ill., a suburb of Chicago; inc. 1956. With a population of c.100 at the time of its establishment on open farmland, the village has grown dramatically and steadily, largely because of its , Ill, American Academy of Pediatrics, 1996 Practice Guidelines * Dulcan M: Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. J Am Acad Adolesc Psychiatry 1997; 36(suppl 10):85S-121S * Greenhill LL, Pliszka S, Dulcan MK, et al: Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 2001; 41(suppl 2):265-495 * American Academy of Pediatrics: Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000; 105:1158-1170 * American Academy of Pediatrics: Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001; 108:1033-1044 * Institute for Clinical Systems Improvement: Diagnosis and Management of Attention Deficit Hyperactivity Disorder in Primary Care, Bloomington, Minn, Institute for Clinical Systems Improvement, 2000. Available at http://www.icsi.org * National Institutes of Health Consensus Development Panel on Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder: Diagnosis and treatment of attention deficit hyperactivity disorder. NIH Consens Statement 1998; 16:1-37. Available at: http://consensus.nih.gov References (1.) Hill J, Schoener E: Age-dependent decline of attention deficit hyperactivity disorder. Am J Psychiatry 1996; 153:1143-1146 (2.) Faraone SV, Biederman J, Spencer T, et al: Attention-deficit/hyperactivity disorder in adults: an overview. Biol Psychiatry 2000; 48:9-20 (3.) Millstein RB, Wilens TE, Biederman J, et al: Presenting ADHD symptoms and subtypes in clinically referred adults. J Allent Disorders 1997; 2:159-166 (4.) American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. : Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (DSM-IV). Washington, DC, American Psychiatric Association, 1994, pp 78-85 (5.) Wolraich M, Felice ME, Drotar D: The Classification of Child and Adolescent Mental Diagnoses in Primary Care. Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child and Adolescent Version. Elk Grove Village, Ill, American Academy of Pediatrics, 1996, pp 93-102 (6.) Dulcan M: Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 1997; 36 (suppl 10):85S-121S (7.) Greenhill LL, Pliszka S, Dulcan MK, et al: Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry 2002; 41 (suppl 2):26S-A S-A abbr. sinoatrial S-A, SA sinoatrial. 9S (8.) American Academy of Pediatrics: Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics 2001; 105:1158-1170 (9.) American Academy of Pediatrics: Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics 2001; 108:1033-1044 (10.) National Institutes of Health: Diagnosis and treatment of attention deficit hyperactivity disorder (ADHD). NIH Consens Statement 1998; 16:1-37 (11.) Taylor MA: Attention-deficit hyperactivity disorder Attention-deficit hyperactivity disorder (ADHD) A condition in which a person (usually a child) has an unusually high activity level and a short attention span. People with the disorder may act impulsively and may have learning and behavioral problems. on the frontlines: management in the primary care office. Compr Ther 1998; 25:313-325 (12.) Gordon N: Attention deficit hyperactivity disorder: possible causes and treatment. Int J Clin Pract 1999; 53:524-528 (13.) Cipkala-Caffin JA: Diagnosis and treatment of attention-deficit/hyperactivity disorder: Perspect Psychiatr Care 1998; 34:18-25 (14.) McGough JJ, McCracken JT: Assessment of attention deficit hyperactivity disorder: a review of recent literature: Curr Opin Pediatr 2000; 12:319-324 (15.) Searight HR, Burke JM, Rottnek F: Adult ADHD: evaluation and treatment in family medicine. Am Fam Physician 2000; 62:2077-2086,2091-2092 (16.) Troller JN: Attention deficit hyperactivity disorder in adults: conceptual and clinical issues. Med J Aust 1999; 171:421-425 (17.) Bresnahan SM, Anderson JW, Barry RJ: Age-related changes in quantitative EEG in attention-deficit/hyperactivity disorder. Biol Psychiatry 1999; 46:1690-1697 (18.) Murphy P, Schachar R: Use of self-ratings in the assessment of symptoms of attention deficit hyperactivity disorder in adults. Am J Psychiatry 2000; 157:1156-1159 (19.) McCann BS, Scheele L, Ward N, et al: Discriminate validity of the Wender Utah Rating Scale for attention-deficit/hyperactivity disorder in adults. J Neuropsychiatry neuropsychiatry /neu·ro·psy·chi·a·try/ (noor?o-si-ki´ah-tre) the combined specialties of neurology and psychiatry. neu·ro·psy·chi·a·try n. Clin Neurosci 2000; 12:240-245 (20.) Schweitzer JB, Cummins TK, Kant CA: Attention-deficit/hyperactivity disorder: advances in the pathophysiology pathophysiology /patho·phys·i·ol·o·gy/ (-fiz?e-ol´ah-je) the physiology of disordered function. path·o·phys·i·ol·o·gy n. 1. and treatment of psychiatric disorders: implications for internal medicine. Med Clin North Am 2001; 85:757-777 (21.) Fargason RE, Ford CV: Attention deficit hyperactivity disorder in adults: diagnosis, treatment, and prognosis. South Med J l994; 87:302-309 (22.) May B, Bos J: Personality characteristics of ADHD adults assessed with the Million Clinical Multiaxial Mul`ti`ax´i`al a. 1. (Biol.) Having more than one axis; developing in more than a single line or plain; - opposed to monoaxial nt>. Inventory-II: evidence of four distinct subtypes. J Pers Assess 2000; 75:237-248 (23.) Biederman J, Wilens TE, Mick E, et al: Does attention-deficit hyperactivity disorder impact the developmental course of drug and alcohol abuse and dependence? Biol Psychiatry 1998; 44:269-273 (24.) Biederman J, Wilens T, Mick E, et al; Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder. Pediatrics 1999; 104:E20 (25.) Lynskey MT, Hall W: Attention deficit hyperactivity disorder and substance use disorders: is there a causal link? Addiction 2001; 96:815-822 (26.) Pelham WE Jr, Wheeler T, Chronis A: Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. J Clin Child Psychol 1998; 27:190-205 (27.) Spencer T, Wilens T, Biederman J, et al: A double-blind, crossover comparison of methylphenidate and placebo in adults with childhood-onset attention-deficit hyperactivity disorder. Arch Gen Psychiatry 1995; 52:434-443 (28.) Wilens TE, Biederman J, Mick E, et al: A systematic assessment of tricyclic antidepressants Antidepressants, Tricyclic Definition Tricyclic antidepressants are medicines that relieve mental depression. Purpose Since their discovery in the 1950s, tricyclic antidepressants have been used to treat mental depression. in the treatment of adult attention-deficit hyperactivity disorder. J Nerv Ment Dis 1995; 183:48-50 (29.) Wilens TE, Biederman J, Prince J, et al: Six-week, double-blind, placebo-controlled study of desipramine desipramine /de·sip·ra·mine/ (des-ip´rah-men) a tricyclic antidepressant of the dibenzazepine class; used as the hydrochloride salt. desipramine a tricyclic antidepressant. for adult attention deficit hyperactivity disorder. Am J Psychiatry 1996; 153:1147-1153 (30.) Wilens TE, Spencer TJ, Biederman J, et al: A controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. of buproprion for attention deficit hyperactivity disorder in adults. Am J Psychiatry 2001; 158:282-288 (31.) Hechtman L: Attention-deficit/hyperactivity disorder: predictors of long-term outcome in children with attention-deficit/hyperactivity disorder. Pediatr Clin North Am 1999; 46:1039-1052 (32.) Mannuzza S, Klein RG: Long-term prognosis in attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin N Am 2000; 9:711-726 (33.) Giedd JN: Bipolar disorder bipolar disorder, formerly manic-depressive disorder or manic-depression, severe mental disorder involving manic episodes that are usually accompanied by episodes of depression. and attention-deficit/hyperactivity disorder in children and adolescents. J Clin Psychiatry 2000; 61 (suppl 9):31-34 (34.) Carey WB: Problems in diagnosing attention and activity. Pediatrics 1999; 103:664-667 (35.) Rapoport JL, Buschbaum MS. Zahn TP, et al: Dextroamphetamine dextroamphetamine /dex·tro·am·phet·amine/ (dek?stro-am-fet´ah-men) the dextrorotatory isomer of amphetamine; used as the sulfate salt in the treatment of narcolepsy and attention-deficit. Abuse of this drug may lead to dependence. in normal boys. Science 1978; 199:560-563 (36.) Jensen PS: Current concepts and controversies in the diagnosis and treatment of attention deficit hyperactivity disorder. Curr Psychiatry Rep 2000; 2:102-109 (37.) Diller LH: Lessons from three-year-olds. Devel Behav Pediatr 2002; 23:S10-S11 (38.) Pelham WE Jr: The NIMH multimodal treatment study for attention-deficit hyperactivity disorder: just say yes to drugs alone? Can J Psychiatry 1999; 44:981-990 (39.) Moline S, Frankenberger W: Use of stimulant medication for treatment of attention-deficit/hyperactivity disorder: A survey of middle and high school students' attitudes. Psychol Schools 2001; 38:569-584 KEY POINTS * Childhood attention-deficit/hyperactivity disorder persists in adults more often than was previously hypothesized, but with a lesser male predominance. * Reassessment of an adult previously diagnosed with childhood attention-deficit/hyperactivity disorder is recommended. * Primary diagnosis of attention-deficit/hyperactivity disorder in adulthood is complicated and usually requires consultation. * The diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adults continues to be problematic because of the lack of definitive diagnostic tests and difficulty in evaluating long-term clinical outcomes. From the Department of Pediatrics, East Tennessee State University East Tennessee State University (ETSU) is an accredited American university, founded October 21911 and located in Johnson City, Tennessee. It is part of the Tennessee Board of Regents system of colleges and universities. , Johnson City; Department of Family and Preventive Medicine preventive medicine, branch of medicine dealing with the prevention of disease and the maintenance of good health practices. Until recently preventive medicine was largely the domain of the U.S. , University of South Carolina--Columbia; and Internal Medicine/Pediatrics, Charleston, SC. Reprint requests to H. Patrick Stern, MD, Department of Pediatrics, East Tennessee State University, PO Box 70578, Johnson City, TN 37614-1708. Reader Opinion |


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It be cool to see a battle with house to house fighting if theres a village/town on the island in the game.
I like to do very CQB in OFP and im building a new comp within the next 2 months so i cant play Arma 2 yet. All the videos ive seen are very far encounters. I want to see how battles are in this game CLOSE UP. I want to see how the AI reacts and just how it "feels" ya know?
So basically if you can have a squad or 2 or more if ur feeling adventurous..lmao of the West moving through a little village/town filled with enemy infantry. Preferably raining/cloudy make the day look gloomy and dreary kind of like that part in Saving Private Ryan when Vin deisel gets shot.

subset: commoncrawl


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New National Policy Strengthens Ocean Conservation
July 19 marked an important day for ocean policy in the United States: after a yearlong process of public meetings, research, and reporting, the Obama Administration's Interagency Ocean Policy Task Force released its Final Recommendations. These recommendations call for a new National Ocean Policy and the establishment of a National Ocean Council to address conservation, economic activity, user conflict, and sustainable use of the ocean, our coasts and the Great Lakes. President Obama signed an executive order to implement the recommendations on the same day.
The United States has never before had a unified policy addressing the many activities taking place in the ocean, along our coasts, and in the Great Lakes. At the time the new policy went into effect, the country had more than 140 different—and often conflicting—laws pertaining to ocean management, which were overseen by twenty different agencies. The new policy provides a comprehensive structure for governing our interactions with the ocean, with an important focus on sustainability, conservation, and stewardship. Furthermore, it recognizes the interconnectedness of all of our water- and land-based activities, as well as the need to consider the ocean's value more prominently in the country's policies. As the policy states:
America's stewardship of the ocean, our coasts, and the Great Lakes is intrinsically and intimately linked to environmental sustainability, human health and well-being, national prosperity, adaptation to climate and other environmental changes, social justice, international diplomacy, and national and homeland security. (p. 14)
One of the key aspects of the new ocean policy is its explicit focus on building resiliency in marine ecosystems, communities, and economies—CORAL's core objective. Recognizing the ocean's central role in shaping the Earth's climate and influencing climate variability, in addition to the impact of increasing carbon dioxide levels on marine ecosystem health, the policy calls for the development of strategies that will increase the resiliency and adaptation of marine and coastal ecosystems to climate change and ocean acidification. Specifically, the policy calls for further research and modeling, better integration of ocean and coastal science into the broader climate dialogue, and science-based changes in management to support resiliency.
This new national policy should generate increased support for the resiliency-building activities that CORAL advocates and puts into practice. Of course, the challenge of implementing the new policy efficiently and effectively still remains, and gaining bi-partisan support for meaningful action will be difficult. However, the successful creation of this policy is a crucial first step in improving the country's stewardship of our marine resources.
Learn more and read the full policy »
Photo by Liz Foote / Hawaii


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Davemuaddib wrote:
For some strange reason the iPhone/iPad app wants to add the regular version of a channel when I add the HD. For example I added channel 803 to my favorites, and suddenly channel 03 appeared as well. When I removed 03, 803 disappeared too. Since i don't use 03 there is no point in it being there. But it's not as simple as saying "Filter HD Only" because my daughter's Nick Jr is not HD. Ideas would be greatly appreciated. Thank you!
Our favorites feature checks your favorites selections against the rest of the channel lineup, and adds other channels that have the same call signs to your favorites as well. We do this so that you can identify all of the channels, including HD channels, where you can watch your favorite shows.
Some lineups actually have network channels (including CBS, NBC, etc) on 3 - 4 different stations, which would make a favorites list look repetitive. Unfortunately right now, there's no way to "un-favorite" one without the other(s). We're working on making this feature more customizable in the future.
Thank you very much for the feedback, though, and stay tuned for enhancements in the near future!
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home > where to stay > hotels and motels > point one resort
24 Winnapaug Rd.
Rhode Island
Web Site: http://www.point1.8k.com/
All rooms come equiped with AC, cable TV, jacuzzi tubs, and a gas fire place. Motel is conviently located near golf courses, casions and beaches.
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Handicap Service: Contact property for current services


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All large corporations maintain a help desk to meet their employee's IT needs simply because help desks ensure that the most appropriate resource is directed at each issue individually. Historically, the infrastructure required to support an in-house help desk has made it cost prohibitive for all but the largest businesses. Just because you aren't a large international conglomerate doesn't mean you have to waste yours and your technical staff's time with various day-to-day support calls. Thanks to our elegant, outsourced help desk process, you can leverage our rich IT experience with the affordability and rapid deployment that in-house solutions simply cannot offer.
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Kirstie Alley is threatened with losing her Clearwater mansion | People
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Actress Kirstie Alley has yet to pay the property tax bill on her mansion overlooking Clearwater Harbor. Alley, best known for her time spent on "Cheers" and more recently "Dancing with the Stars," is also known for her participation in Scientology, which influenced her decision to purchase the real estate.
She bought the mansion to be closer to the Church of Scientology headquarters in Clearwater, Florida. Alley purchased the mansion for $1.8 million in 2008.
However,according to Pinellas County property tax records, Alley stopped paying her property taxes last year and currently owes $41,395.23.
A spokesman released a statement last Thursday saying "We were not aware of the amount owed, and her accountant never received the bill." Alley says she will pay the property tax bill in the near future. She has until April 2013 or the property will go up for auction.
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text: RE: DRAFT charter2004-03-15 19:04:33This makes sense to me. It should be emphasized that the decision to exclude other technologies in this particular group does not in any way prevent them from being raised and persued independly in other groups. What could foreclose these groups though would be a scheme that was strictly limited to information to support MTA authentication by IP address with no provision made to allow any other form of information to ever be included. I am a little concerned that we have the 'authorization' language in the draft. There is a concrete distinction here as to scope. The 'describe the configuration of a mail server' point of view would cover information such as the IP address of the mail server and could also extend to other information that would help the email sender persuade the recipient that a message is not spam, in particular accreditation information such as the accreditation information that a Bonded Sender might provide. Clearly we do not want to define the protocol by which such accreditations would be verified in this group. But they are a core component of the accountable sender scheme that was developed at the Aspen institute roundtable and of the Microsoft CSRI proposal. It has also been discussed at length in the SPF group. It should be possible to inform the recipient that an accreditation exists. I can explain later why this is sufficient. I would respectfully suggest that this be allowed into the scope. Phill -----Original Message----- From: owner-ietf-mxcomp(_at_)mail(_dot_)imc(_dot_)org [mailto:owner-ietf-mxcomp(_at_)mail(_dot_)imc(_dot_)org]On Behalf Of Ted Hardie Sent: Monday, March 15, 2004 6:13 PM To: ietf-mxcomp(_at_)imc(_dot_)org Subject: DRAFT charter Below is a DRAFT charter; I believe it reflects the consensus of the meeting, has a reasonable description of the aim of the group, and reflects a strong project management focus, designed to help us meet the timeline we need to make this work relevant. The two proposed Chairs, Marshall Rose and Andy Newton, are both experienced and I believe they will work well together.. This draft is on the IESG agenda for this week, for internal review; comments to the list, Chairs, me, or IESG are all appropriate. I hope, however, that we can focus on the big picture here, as spending too much time on the charter will seriously hurt our ability to get this work done. regards, Ted Hardie MTA Authorization Records in DNS (MARID) Chairs: Marshall Rose <mrose+mtr(_dot_)mxcomp(_at_)dbc(_dot_)mtview(_dot_)ca(_dot_)us> Andrew Newton <andy(_at_)hxr(_dot_)us> Applications Area Directors: Ted Hardie <hardie(_at_)qualcomm(_dot_)com> Scott Hollenbeck <sah(_at_)428cobrajet(_dot_)net> Applications Area Advisor: Ted Hardie <hardie(_at_)qualcomm(_dot_)com> Mailing Lists: General Discussion: ietf-mxcomp(_at_)imc(_dot_)org To Subscribe: ietf-mxcomp-request(_at_)imc(_dot_)org In Body: Subscribe Archive: http://www.imc.org/ietf-mxcomp/index.html Description of Working Group: It would useful for Mail Transfer Agents (MTAs) to be able to confirm that peer MTAs are authorized to send mail on behalf of a specific domain or network. This working group will develop a DNS-based mechanism for storing and distributing information associated with that authorization. While the primary current use case for this facility is to combat a certain class of domain forgery in spam, the solution chosen should be generally usable for MTA authorization. This working group is being chartered after extensive discussion of the issues in the IRTF's Anti-spam Research Group, and it is presumed that all active participants will be familiar with the documents produced there which describe the problem. This working group is not, however, an extension of that research group; it has no general writ to study spam or to produce specifications on the topic. It will not consider anti-spam abatement measures outside of the area of MTA authorization. An individual message may be associated with multiple identities (specifically the domains present in the RFC2822 From, RFC2822 Sender, the SMTP Mail-From, and the SMTP EHLO), the first task of the working group will be to establish which of these identities should be associated with MTA authorization. Once this decision has been reached, it will limit the scope of further activity in this working group, and the chairs will rule out of order discussion related to schemes which use other identities as the basis of authorization. Upon chartering of this working group, the IESG intends to request that the IRTF Chair and the Chairs of the IRTF's Anti-Spam Research Group seek publication of the listed input documents as experimental RFCs, so that they are available on an archival basis; the IESG also intends to request that the RFC editor insert a note into each document informing the reader that the IETF's MARID working group has taken on the task of producing a standard in this area. Working Group Goals and Milestones: March 04 Discuss identities with which MTA authorization should be associated April 04 Publish one or more proposals, as I-Ds, specifying the required semantics used for MTA authorization. April 04 Working Group last call on which identities will be used for MTA authorization May 04 Interim Meeting to determine which semantics proposal to use. May 04 Publish one or more syntax proposals, as I-Ds, to meet required semantics June 04 Final selection of syntax and document review of selected proposal July 04 Working group last call Aug 04 Submit working group document on MTA Authorization Record in DNS to PS. Aug 04 Enter FIN_WAIT Input documents: draft-irtf-asrg-lmap-discussion draft-stumpf-dns-mtamark draft-brand-drip draft-danisch-dns-rr-smtp draft-fecyk-dmp draft-mengwong-spf draft-levine-fsv


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- March 27, 2012
- 3:54 a.m.
- Suggest removal
- Reply to this post
cornandbeans writes:
thank you. Not all Collier County residents are tea toting fascist republicans. Some are democrats, some are rational, compasionate republicans.
We wish you well.
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I like to fantasize about being spanked when I masturbate, and I'm wondering if I would like it in real life sex play, too. Trouble is, I'm a little nervous about the idea of actually trying it out, and I'm too embarrassed to ask my boyfriend if he'd be cool with that! What should I do?
For many young people, Robin Thicke's hit single "Blurred Lines" has become the anthem of the summer. Recently topping the Billboard Hot 100 list and rising to the position of most-downloaded song on iTunes, "Blurred Lines" seems to be thumping out of every stereo speaker on the planet. And for good reason -- it's a very catchy song, with a strong beat and ostensibly fun lyrics. It also comes along with a controversial video full of naked women, which has no doubt amped up its notoriety. Like many artists before him, Thicke sings about a complex topic -- sex -- but he makes the mistake of ignoring a crucial underlying issue: consent.
Throughout the song, Thicke addresses a woman he perceives as a potential sex partner, continuously making assumptions about her sexual intentions. He sings that he's "gon' take [have sex with]" her, repeatedly insisting, "I know you want it". (He also calls said woman a bitch, an animal, and refers to himself as pimping.)
In the middle of the chorus, Th
Read more...I only have one labia minora. One is not smaller than the other, I only have ONE. It doesn't hurt, but I'm scared guys will be turned off by it. Is it normal?
Help! I'm in a relationship with a man (I identify as a straight woman) who identifies as queer. He's mostly had sex with men in the past (there might have been 1 woman), but this is first heterosexual relationship. It's also my first relationship with a queer man. I really care for him, but I am struggling with checking my own heteronormative attitudes. For example, I don't know how to get over the fact that he enjoys watching gay porn, and mostly gets off to men. We still have great sex together and I know he is attracted to me, and I try to remind myself of this when I find myself getting bothered by what turns him on. I'm learning to love, not accept, that he is queer and that he has made me shift my thinking about relationships and sexuality so much. However, I still don't know how to get myself out of these moments, sometimes ongoing, of insecurity.
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On the day entries are available on a 'first come, first served' basis and providing pre-booked entries have not sold-out. There is a £2.50 administration surcharge for on the day entries.
Before you arrive
1. We will send you a pre-ride email to confirm details for on the day. We also update the RideIt! Blog with event news. Before arriving to ride at RideIt! we strongly advise that you check that your bike is in full working condition.
2. Wearing a helmet is compulsory at all rides. If you arrive without a helmet you will be refused entry and your entry fee refunded. View our range of helmets available to purchase online.
On the Day
1. Arrive and register at the event center from 08.00am. You will be given a timing chip, FREE Waterproof OS route map & FREE SIS energy product. Start by heading to the start line when you are ready. You will be given a rider briefing to explain the course signs and important route information.
Start times are as follows:
Registration Open: 08:00 - 10:30
Long Route Riders Start: 08:30 - 09:45
Fun/Short/ Medium Route Riders Start: 08:30 - 10:30
Last entry to the Route: 10:45
Event Centre Closes: 17:00
* Challenge rides-King of the Downs and King of the Pennines have alternative staggered start times - please see individual event pages.
3. There is a mechanic and drink stops en-route but we advise you take spare food and drink as parts of the routes are rural and not near shops.
4. All of the routes are marked with arrows and marker ribbon. Follow the direction of the arrows and if ribbon is on your right, turn right (if the ribbon is on your left, turn left).
We are very careful to clearly mark our routes and check them before the ride, therefore if you find that you are cycling along and you have not seen an arrow for a while; stop, consult your map, check with other riders or find a landmark and give the team a call.
5. Finish and report to a member of the RideIt! Failure to report back may result in you being presumed lost and emergency services being called.
Finished the ride and changed your route? No problem just let us know when you hand your timing chip back.
Standard Entry Prices:
• Adult - Fun road route £5.00
• Adult - All other routes £15.00
• Child - 16 and under) - FREE
*On the day entries will incur a £2.50 surcharge. Special prices are available at certain rides (Night Rides, King of the Downs, King of the Pennines, TCR Show RideIt!) - see the relevant event page for entry fees.
We're passionate about cycling and enjoy nothing more than instilling that passion in younger riders. That's why all kids under 16 years of age ride free when accompanied by a paying adult. By purchasing an event entry you agree to our Ride It! terms and conditions.
A donation from every RideIt! entry goes to Leukaemia and Lymphoma Research charity.
This story was last updated on 07/10/2013


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Authentic Neopolitan Italian food served in a comfortable and laid back atmosphere, where the owner can often be seen walking amonst the tables singing or getting the crowd up for an impromptu party ! A Bloomingdale landmark where celebrities often dine.
This is THE place to go to for outstanding Italian Cusine! The owner (and entertainer) Tony Spavone sings everything from old Italian Classics to modern tunes, and has been doing it for 25 years! We had the BEST time we ever experienced when we were there! At one point you thought you were at an Italian wedding...he had the entire... More
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Kyle, Mike and Sam answer emails and take phone calls. We also talk about a show on KLAY called "The Last Word", a religious show immediately following ours, which exists only to refute our arguments and troll us. In short, they make a severe misstep.
Danger! Death Emails!
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Episode S6E9: Danger! Death Emails!
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Frequent uninitiated USB disconnects
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text: This image is copyright free and in the public domain anywhere that extends copyrights 70 years after death or at least 120 years after publication when the original illustrator is unknown. Hiding FrogVintage drawing of a frog hiding in plain site near a large plant. I'll leave it to you to decide to use this drawing as it appeared or to crop out either the frog or the plant. This black and white line drawing looks much like a rubber stamp image and would look great colorized. Artist: Dugald Stewart Walker (1883-1937) Image Appears In: The Peacock and the Wishing Fairy Date Image Published: 1921 Check out ourAbout Us page for more information on Copyright Durations. Another copyright free and public domain image brought to you by ReusableArt.com and our valued sponsors. |