Research in Developmental Disabilities 34 (2013) 2127–2132

Contents lists available at SciVerse ScienceDirect

Research in Developmental Disabilities

Outpatient rehabilitation utilization and medical expenses in

children aged 0–7 years with ADHD: Analyses of
population-based national health insurance data
Jin-Ding Lin *, Yi-Hsin Chen, Lan-Ping Lin
School of Public Health, National Defense Medical Center, Taipei, Taiwan

A R T I C L E I N F O A B S T R A C T

Article history: Medical costs of attention-deficit/hyperactivity disorder (ADHD) are substantial and have
Received 6 January 2013 a large impact on the public health system. The present study presents information
Received in revised form 27 March 2013 regarding outpatient rehabilitation care usage and medical expenditure for children with
Accepted 28 March 2013 ADHD. A cross-sectional study was conducted by analyzing data from the Taiwan National
Available online 30 April 2013 Health Insurance claims database for the year 2009. A total of 6643 children aged
0–7 years with ADHD (ICD-9-CM codes 314.0x: attention deficit disorder, 314.00:
Keywords: attention deficit disorder without hyperactivity, or 314.01: attention-deficit disorder with
Attention-deficit/hyperactivity
hyperactivity) who had used outpatient rehabilitation care were included in the analyses.
disorder (ADHD)
Results showed that the mean annual rehabilitation care was 22.24 visits. Among the care
Outpatient
Rehabilitation
users, 76% of patients were male, and 24% were female. More than half of the children with
Medical expenditure ADHD had comorbid mental illnesses as well. A logistic regression analysis of outpatient
Medical cost rehabilitation expenditure (low vs. high) showed that of those children with ADHD, those
aged 0–2 years tended to incur more medical costs than those aged 6–7 years. Other
factors such as frequency of rehabilitation visits, hospital medical setting and ownership,
location of medical care setting, and types of rehabilitation were also significantly
correlated with medical expenditure. The results from this study suggest that health care
systems should ensure accurate diagnosis and measurement of impairment to maintain
appropriate and successful management of rehabilitation needs for children with ADHD.
ß 2013 Elsevier Ltd. All rights reserved.

1. Introduction

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent neurobehavioral disorders of childhood.
Children with ADHD exhibit a number of associated symptoms and impairments in development, socialization, emotional
and cognitive functioning and behavior problems (Remschmidt & Global ADHD Working Group, 2005). ADHD has three
subtypes: predominantly hyperactive-impulsive, predominantly inattentive, and combined hyperactive-impulsive and
inattentive (The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision; DSM-IV-TR
Workgroup, 2000). Diagnosing ADHD is a complex process that requires a patient to exhibit multiple symptoms,
demonstrate significant problems with daily life in several major areas (work, school, or friends), and have had the
symptoms for a minimum of six months (Attention Deficit Disorder Association, 2012). The prevalence of ADHD in the
United States was 6–9% in youth and 3–5% in adults (Dopheide & Pliszka, 2009). In Germany, the overall lifetime prevalence

* Corresponding author at: School of Public Health, National Defense Medical Center, No. 161, Min-Chun East Road, Section 6, Nei-Hu, Taipei, Taiwan.
Tel.: +886 2 87923100x18447; fax: +886 2 87923147.
E-mail addresses: a530706@ndmctsgh.edu.tw, jack.lin1964@gmail.com (J.-D. Lin).

0891-4222/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ridd.2013.03.034
2128 J.-D. Lin et al. / Research in Developmental Disabilities 34 (2013) 2127–2132

of ADHD diagnosis was 4.8%, and there was a significant gender difference between boys (7.7%) and girls (1.8%) (Huss,
Holling, Kurth, & Schlack, 2008). ADHD has been associated with substantially elevated prevalence of the following: learning
disabilities, conduct disorder, anxiety, depression and speech problems (Larson, Russ, Kahn, & Halfon, 2011). Clinical
evidence has shown that the most effective treatment for ADHD is a combination of medication, behavioral therapy or
counseling to learn coping skills and adaptive behaviors, parenting education and support (Jaksa, 1998).
The annual cost of ADHD is substantial and has a large economic impact in the United States (Birnbaum et al., 2005). Doshi
et al. (2012) estimated that the overall national annual incremental costs of ADHD ranged from $143 to $266 billion (B). For
children, the largest costs were attributed to health care ($21B–$44B). In North Dakota, 1.9% of total health expenditures for
children was attributable to ADHD (Burd, Klug, Coumbe, & Kerbeshian, 2003). Children with ADHD use significantly more
health care resources and incur significantly higher costs than children without ADHD (Guevara, Lozano, Wickizer, Mell, &
Gephart, 2001). Due to the complexity of ADHD, early utilization of rehabilitation such as occupational, physical, hearing and
speech therapies is crucial. However, general information regarding rehabilitation care use among ADHD patients in Taiwan
is lacking. Therefore, the present study aims to describe the association between children with ADHD and medical costs.
Nationwide data were collected from national health insurance beneficiaries in Taiwan concerning outpatient rehabilitation
care usage and medical expenditures of this vulnerable population.

2. Methods

A cross-sectional study was conducted by analyzing data from a Taiwan National Health Insurance (NHI) claims database
for the year 2009. Data included gender, date of birth, outpatient care expenditure, amount of outpatient rehabilitation visits,
medical care setting and clinical division, and discharge diagnosis of disease according to the International Classification of
Diseases, 9th revision, Clinical Modified (ICD-9-CM) coding system, which is used by Taiwan NHI. ADHD is a diagnosis given
to children and adults who consistently and persistently display certain characteristic behaviors. The most common core
features include distractibility, impulsivity, and hyperactivity. Analysis in the present study was restricted to children aged
0–7 years with at least 1 diagnosis of ADD/ADHD (ICD-9-CM codes 314.0x: attention deficit disorder, 314.00: attention
deficit disorder without hyperactivity, or 314.01: attention-deficit disorder with hyperactivity) and at least 1 outpatient
rehabilitation claim. The cases of ADD/ADHD were identified and diagnosed by qualified medical doctors and coded for
medical billing. We also analyzed comorbidity with mental illness (codes 299–319) among children with ADHD. The mental
illnesses included were psychosis (290–299), neurotic disorders, personality disorders, and other nonpsychotic mental
disorders (300–316), and mental retardation (317–319).
Data were analyzed by SPSS 18.0 software. The methods including number, percentage, standard deviation (SD), mean,
and Chi-square test (x2) were used to describe demographic, medical care setting characteristics and rehabilitation care
expenditure of children with ADHD. A logistic regression analysis was used to test the associated factors of rehabilitation
care expenditure of children with ADHD.

3. Results

Table 1 shows that 6643 children aged 0–7 years with ADHD had used outpatient rehabilitation care in the national
health insurance program during the year 2009. The mean of annual rehabilitation care was 22.24 visits, with 26.1% children
reported as higher users (>22.24 visits) in the study. Among the care users, 5049 (76%) were male patients and 1594 (24%)
were female patients. Children aged 3–5 years (65.4%) used more rehabilitation care than children aged 0–2 years (10.8%) or
those aged 6–7 years (23.8%). More than half of children with ADHD (50.7%) had comorbid mental illnesses, and a few of such
cases were diagnosed with significant diseases (0.3%). Two percent of children with ADHD came from low income families,
and most of the cases resided in urban cities.
Table 2 presents data for rehabilitation care settings used by children with ADHD in 2009. Patients were more likely to use
hospitals (54.3%) rather than clinics (45.7%), and most of the cases were in North Taiwan (Taipei and North areas). Patients
typically used the rehabilitation (88.6%), psychiatry (7.6%) and pediatric divisions (3.7%). Among outpatient rehabilitation
visits, the top three types used were occupational therapy (OT) (65.6%), rehabilitation evaluation (15.6%) and physical
therapy (PT) (10.3%).
Table 3 describes the annual outpatient rehabilitation care expenditure in 2009. Among the cases used in the study, the
total claims number was 453,441,209 points (1 point is nearly 1 New Taiwan Dollar), which amounted to 18.6% of the total
medical care expenditures among children within the age range of 0–7 years. The results also show that OT (56.1%) and PT
(23.0%) consumed more expenditure than other treatment types among rehabilitation visits.
Tables 4 and 5 present data on the relationship of associated factors and low or high rehabilitation expenditure claims in
single variant analyses. Results from x2 tests show that age, comorbidity with mental illnesses, high rehabilitation visit
usage, medical setting and ownership, location of medical setting, clinical division and types of rehabilitation were all
significantly associated with patient rehabilitation expenditure. Table 6 illustrates a logistic regression analysis of outpatient
rehabilitation expenditure (low vs. high). Results show that children with ADHD aged 0–2 years tended to use more medical
cost than those aged 6–7 years. Other factors such as higher frequency of rehabilitation visit, hospital medical setting and
ownership, location of medical care setting, and type of rehabilitation were significantly correlated with medical
expenditure in the study.
 J.-D. Lin et al. / Research in Developmental Disabilities 34 (2013) 2127–2132 2129

Table 1
The demographic characteristics of children with ADHD who used outpatient rehabilitation care in 2009 (n = 6643).

Variable n (%)

Gender
Boys 5049 (76.0)
Girls 1594 (24.0)
Age
0–2 718 (10.8)
3–5 4343 (65.4)
6–7 1582 (23.8)
Comorbidity with mental illnesses
Yes 3368 (50.7)
No 3275 (49.3)
Comorbidity with significant illnessesa
Yes 18 (0.3)
No 6625 (99.7)
Low income family
Yes 138 (2.1)
No 6505 (97.9)
Urbanization level of residenceb
I 2723 (41.2)
II 1888 (28.5)
III 1196 (18.1)
IV 541 (8.2)
V 70 (1.1)
VI 96 (1.5)
VII 95 (1.4)
Visits of rehabilitation carec
Low 4910 (73.9)
High 1733 (26.1)
a
Severe illnesses defined by Taiwan Bureau of National Health Insurance, of which the patient can be partially waived from medical costs.
b
High to low urbanization level: I–VII.
c
Low: <22.24, high: 322.24 (mean of annual visits = 22.24).

Table 2
The characteristics of rehabilitation care settings used by children with ADHD 2009 (n = 6643).

Variable n (%)

Medical setting
Clinic 3039 (45.7)
Hospital 3604 (54.3)
Ownership
Public hospital 827 (12.4)
Private hospital 1128 (17.0)
Private cooperate hospital 1649 (24.8)
Clinic 3039 (45.7)
Location of medical setting
Taipei 3476 (52.3)
North 1137 (17.1)
Central 842 (12.73)
South 611 (9.2)
Kaohsiung and Pingtung 465 (7.0)
East 112 (1.7)
Clinical division
Pediatric 243 (3.7)
Psychiatry 507 (7.6)
Rehabilitation 5888 (88.6)
Other 5 (0.1)
Types of rehabilitation
Physical therapy 686 (10.3)
Occupational therapy 4361 (65.6)
Speech therapy 484 (7.3)
Psycho-social therapy 77 (1.2)
Rehabilitation exam (evaluation) 1035 (15.6)
2130 J.-D. Lin et al. / Research in Developmental Disabilities 34 (2013) 2127–2132

Table 3
Medical care expenditure claims of children with ADHD in 2009 (unit: pointa).

Types (n = 6643) Claim points Percent

Total medical fee 2,433,892,608 100

Rehabilitation total fee 453,441,209 18.6b
Physical therapy 104,193,808 23.0c
Occupational therapy 254,503,255 56.1d
Speech therapy 44,660,145 9.9e
Psycho-social therapy 4,031,140 0.9f
Rehabilitation exam 46,052,861 10.1g
a
1 Claim point roughly equal to 1 New Taiwan Dollar.
b
(Rehabilitation fee/total medical fee)  100.
c
(Physical therapy/rehabilitation total fee)  100.
d
(Occupational therapy/rehabilitation total fee)  100.
e
(Speech therapy/rehabilitation total fee)  100.
f
(Psycho-social therapy/rehabilitation total fee)  100.
g
(Rehabilitation exam/rehabilitation total fee)  100.

Table 4
Association of children’s characteristics and rehabilitation expenditure by Chi-square tests (n = 6643).

Variables Rehabilitation expenditure x2 p-Value

Low; n (%) High; n (%)

Gender 1.560 0.212

Boys 3768 (56.7) 1281 (19.3)
Girls 1215 (18.3) 379 (5.7)
Age 9.173 0.010
0–2 571 (8.6) 147 (2.2)
3–5 3230 (48.6) 1113 (16.8)
6–7 1182 (17.8) 400 (6.0)
Mental illness 106.287 <0.0001
No 2639 (39.7) 636 (9.6)
Yes 2344 (35.3) 1024 (15.4)
Significant illness
No 4970 (74.8) 1655 (24.9) 0.0001 0.999
Yes 13 (0.2) 5 (0.1)
Low income family 0.160 0.689
No 4882 (73.5) 1623 (24.4)
Yes 101 (1.5) 37 (0.6)
Residence urbanization level 13.928 0.052
I 2072 (31.3) 651 (9.8)
II 1367 (20.7) 521 (7.9)
III 904 (13.7) 292 (4.4)
IV 408 (6.2) 133 (2.0)
V 53 (0.8) 17 (0.3)
VI 81 (1.2) 15 (0.2)
VII 69 (1.0) 26 (0.4)
Rehabilitation visits 4491.395 <0.0001
Low 4722 (71.1) 188 (2.8)
High 261 (3.9) 1472 (22.4)

4. Discussion

ADHD, a frequently diagnosed behavioral disorder that exists across different cultures, represents a costly major public
health problem that should consistently be diagnosed and effectively treated (Remschmidt & Global ADHD Working Group,
2005). The prevalence of comorbidities in children with ADHD appears to vary among different age ranges (Takeda,
Ambrosini, deBerardinis, & Elia, 2012). However, ADHD is currently underdiagnosed and undertreated in many countries,
leading to ineffective treatment and higher costs of associated with the illness (Kooij et al., 2010). The present study provides
data describing outpatient rehabilitation care use and medical expenditure for children with ADHD. Results show that the
annual rehabilitation care was high (mean = 22 visits) and that more than half of the children with ADHD also suffered from
mental illnesses, necessitating additional attention of public health services.
Previous studies have also shown that patients with ADHD exhibited substantially greater use of medical care when
compared with persons without ADHD in multiple care delivery settings (Leibson, Katusic, Barbaresi, Ransom, & O‘Brien,
2001). Most children with ADHD have at least 1 comorbid disorder: 33% had 1, 16% had 2, and 18% had 3 or more (Larson
et al., 2011). In Belgium, De Ridder and De Graeve (2006) found that childhood ADHD results in a significantly higher use of
 J.-D. Lin et al. / Research in Developmental Disabilities 34 (2013) 2127–2132 2131

Table 5
Association of medical settings and rehabilitation expenditure by Chi-square test (n = 6643).

Variables Rehabilitation expenditure x2 p-Value

Low; n (%) High; n (%)

Medical setting 230.514 <0.0001

Clinic 2547 (38.3) 492 (7.4)
Hospital 2436 (36.7) 1168 (17.6)
Ownership 426.970 <0.0001
Public hospital 656 (9.9) 171 (2.6)
Private hospital 588 (8.9) 540 (8.1)
Cooperate hospital 1192 (17.9) 457 (6.9)
Clinic 2547 (38.3) 492 (7.4)
Location of medical setting 177.410 <0.0001
Taipei 2529 (38.1) 947 (14.3)
North 769 (11.6) 368 (5.5)
Central 728 (11.0) 114 (10.7)
South 539 (8.1) 72 (1.1)
Kaohsiung and Pingtung 332 (5.0) 133 (2.0)
East 86 (1.3) 26 (0.4)
Clinical division 107.514 <0.0001
Pediatric 212 (3.2) 31 (0.5)
Psychiatry 457 (6.9) 50 (0.8)
Rehabilitation 4310 (64.9) 1578 (23.8)
Other 4 (0.1) 1 (0)
Types of rehabilitation 202.600 <0.0001
Physical therapy 370 (5.6) 316 (4.8)
Occupational therapy 3399 (51.2) 962 (14.5)
Speech therapy 322 (4.8) 162 (2.4)
Psycho-social therapy 69 (1.0) 8 (0.1)
Rehabilitation exam 823 (12.4) 212 (3.2)

Table 6
Logistic regression model of rehabilitation expenditure (low vs. high) of children with ADHD.

Variable (reference) b Wald OR (95% CI) p-Value

Constant 3.593 4.824 0.028

Age (0–2)
3–5 0.152 0.712 0.859 (0.603–1.223) 0.399
6–7 0.493 5.745 0.611 (0.408–0.914) 0.017
Low income family (no)
Yes 0.127 0.132 1.135 (0.572–2.255) 0.717
Outpatient visits (low)
High 5.487 1645.048 241.482 (185.24–314.80) <0.0001
Medical setting (clinic)
Hospital 1.482 88.248 4.401 (3.230–5.995) <0.0001
Medical setting ownership (clinic)
Public 0.181 0.666 1.198 (0.776–1.848) 0.415
Private 0.585 10.742 1.794 (1.265–2.545) 0.001
Cooperate and other 0.664 77.015 1.943 (1.675–2.254) <0.0001
Setting location (East)
Taipei 0.566 2.363 0.568 (0.276–1.168) 0.124
North 0.667 2.981 0.513 (0.241–1.094) 0.084
Central 1.293 10.230 0.274 (0.124–0.606) 0.001
South 1.960 22.620 0.141 (0.063–0.316) <0.0001
Kaohsiung and Pingtung 0.398 0.946 0.671 (0.301–1.499) 0.331
Clinical division (other)
Pediatric 0.538 0.121 1.712 (0.082–35.584) 0.728
Psychiatry 0.817 0.280 2.265 (0.110–46.676) 0.596
Rehabilitation 0.737 0.234 2.090 (0.105–41.496) 0.629
Type of rehabilitation (physical therapy)
Occupational therapy 1.011 32.336 0.364 (0.257–0.515) <0.0001
Speech therapy 0.124 0.293 0.884 (0.565–1.383) 0.588
Psycho-social therapy 1.961 8.455 0.141 (0.037–0.528) 0.004
Rehabilitation exam 0.889 18.181 0.411 (0.273–0.619) <0.0001

healthcare. Children with ADHD have a significantly higher probability of visiting a general practitioner and a specialist, and
they also visit the emergency department and are hospitalized significantly more often than children without ADHD.
Our study found that the annual outpatient rehabilitation care expenditure amounted to 18.6% of the total medical care
expenditure in children aged 0–7 years with ADHD. OT and PT comprised more of the expenditure than other treatments
2132 J.-D. Lin et al. / Research in Developmental Disabilities 34 (2013) 2127–2132

among rehabilitation visits. Children with ADHD also incur high medical expenditures in other countries. In the Netherlands,
the mean direct medical costs per ADHD patient per year were 2040 euros compared to 288 euros for children with behavior
problems and 177 euros for children with no behavior problems (Hakkaart-van Roijen et al., 2007). In a US Medical
Expenditure Panel Survey, children with ADHD had significantly higher mean total health care costs ($1151) compared with
children with asthma ($1091), and with the general population ($712) (Chan, Zhan, & Homer, 2002). Pelham, Foster, and
Robb (2007) estimated the annual cost of illness for ADHD in children and adolescents to be between $12,005 and $17,458
per individual (2005 dollars). Using a prevalence rate of 5%, a conservative estimate of the annual societal cost of illness for
ADHD is $42.5 billion, with a range between $36 billion and $52.4 billion.
Variation of medical care settings and professionals will result in different types of services used by children with ADHD,
as well as variation in medical expenditure. Cross-sectional data provide limited information for the determinants of
rehabilitation care utilization by patients with ADHD. However, our study presents the very first data in Taiwan outlining
medical care usage among children with ADHD. The data show that the outpatient rehabilitation expenditure is significantly
affected by frequency of visits, service settings, location and rehabilitation types. We suggest that future studies should
ensure accurate diagnosis and measurement of impairment to enable appropriate and successful management of
rehabilitation needs for this population. In addition, ADHD is a persistent condition that needs to be treated and monitored
over time. Children treated for ADHD need follow-up visits to ensure efficacy of medication and continuing support for
patients in treatment (Gardner, Kelleher, Pajer, & Campo, 2004). Furthermore, clinical management of ADHD must address
multiple comorbid conditions and manage a range of adverse functional outcomes (Larson et al., 2011).

Conflict of interest

The authors declare that they have no conflicts of interest with regard to the content of this article. The data were
provided by the Taiwan Bureau of National Health Insurance and were managed by the National Health Research Institutes.
The interpretation and conclusions herein do not represent those departments.

References

Attention Deficit Disorder Association. (2012). ADHD awareness week – 7 Facts you need to know about ADHD. http://www.add.org/.
Birnbaum, H. G., Kessler, R. C., Lowe, S. W., Secnik, K., Greenberg, P. E., Leong, S. A., et al. (2005). Costs of attention deficit–hyperactivity disorder (ADHD) in the US:
Excess costs of persons with ADHD and their family members in 2000. Current Medical Research and Opinion, 21, 195–206.
Burd, L., Klug, M. G., Coumbe, M. J., & Kerbeshian, J. (2003). Children and adolescents with attention deficit–hyperactivity disorder: 1. Prevalence and cost of care.
Journal of Child Neurology, 18, 555–561.
Chan, E., Zhan, C., & Homer, C. J. (2002). Health care use and costs for children with attention-deficit/hyperactivity disorder: National estimates from the medical
expenditure panel survey. Archives of Pediatrics and Adolescent Medicine, 156, 504–511.
De Ridder, A., & De Graeve, D. (2006). Healthcare use, social burden and costs of children with and without ADHD in Flanders, Belgium. Clinical Drug Investigation,
26, 75–90.
Dopheide, J. A., & Pliszka, S. R. (2009). Attention-deficit–hyperactivity disorder: An update. Pharmacotherapy, 29, 656–679.
Doshi, J. A., Hodgkins, P., Kahle, J., Sikirica, V., Cangelosi, M. J., Setyawan, J., et al. (2012). Economic impact of childhood and adult attention-deficit/hyperactivity
disorder in the United States. Journal of the American Academy of Child and Adolescent Psychiatry, 51, 990–1002.
Gardner, W., Kelleher, K. J., Pajer, K., & Campo, J. V. (2004). Follow-up care of children identified with ADHD by primary care clinicians: A prospective cohort study.
Journal of Pediatrics, 145, 767–771.
Guevara, J., Lozano, P., Wickizer, T., Mell, L., & Gephart, H. (2001). Utilization and cost of health care services for children with attention-deficit/hyperactivity
disorder. Pediatrics, 108, 71–78.
Hakkaart-van Roijen, L., Zwirs, B. W., Bouwmans, C., Tan, S. S., Schulpen, T. W., Vlasveld, L., et al. (2007). Societal costs and quality of life of children suffering from
attention deficient hyperactivity disorder (ADHD). European Child and Adolescent Psychiatry, 16, 316–326.
Huss, M., Holling, H., Kurth, B., & Schlack, R. (2008). How often are German children and adolescents diagnosed with ADHD? Prevalence based on the judgment of
health care professionals: Results of the German health and examination survey (KiGGS). European Child and Adolescent Psychiatry, 17, 52–58.
Jaksa, P. (1998). Attention deficit hyperactivity disorder (ADHD/ADD) fact sheet. http://www.add.org/?page=ADHD_Fact_Sheet.
Kooij, S. J., Bejerot, S., Blackwell, A., Caci, H., Casas-Brugué, M., Carpentier, P. J., et al. (2010). European consensus statement on diagnosis and treatment of adult
ADHD: The European Network Adult ADHD. BMC Psychiatry, 10, 67.
Larson, K., Russ, S. A., Kahn, R. S., & Halfon, N. (2011). Patterns of comorbidity, functioning, and service use for US children with ADHD, 2007. Pediatrics, 127, 462–
470.
Leibson, C. L., Katusic, S. K., Barbaresi, W. J., Ransom, J., & O‘Brien, P. C. (2001). Use and costs of medical care for children and adolescents with and without
attention-deficit/hyperactivity disorder. Journal of American Medical Association, 285, 60–66.
Pelham, W. E., Foster, E. M., & Robb, J. A. (2007). The economic impact of attention-deficit/hyperactivity disorder in children and adolescents. Ambulatory
Pediatrics, 7, S121–S131.
Remschmidt, H. Global ADHD Working Group. (2005). Global consensus on ADHD/HKD. European Child and Adolescent Psychiatry, 14, 127–137.
Takeda, T., Ambrosini, P. J., deBerardinis, R., & Elia, J. (2012). What can ADHD without comorbidity teach us about comorbidity? Research in Developmental
Disabilities, 33, 419–425.
Workgroup, D.S.M.-I.V-T.R. (2000). The diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: American Psychiatric
Association.