ADHD Diagnosis and Evaluation Robin K. Blitz, MD. ADHD DIAGNOSTIC CLINIC Week 1

Transcription

1 ADHD Diagnosis and Evaluation Robin K. Blitz, MD ADHD DIAGNOSTIC CLINIC Week 1

2 ADHD What is it? A neurodevelopmental disorder Developmentally inappropriate levels of hyperactivity, impulsivity, and inattention Impairment in executive function and behavioral self-regulation Frequent co-morbidities: mood, conduct, learning disorders Impairment in functioning in at least 2 settings (home, school, social)

3 ADHD: A Brain-based Disorder

4 ADHD: Core Symptoms Hyperactivity Whole body restlessness Fidgetiness Peaks by 8 years of age May continue as mental restlessness Impulsivity - the core symptom? Difficulty with self-regulation and response inhibition (gas and brakes) Inattention - more cognitive impairment Distractibility (sustained attention) Interest vs Importance-based learning The Nintendo effect

5 ADHD: Significant Associated Symptoms Academic Skills Deficit Problems with academic productivity and accuracy Social Skills Deficit Problems with social interactions peers and family in school and at home Impulsive Aggression Motor Coordination Difficulties Speech and Language Disorders Sleep Difficulties

6 ADHD and Coexisting Conditions Evaluation for ADHD should include assessment for Conduct (10%) co-existing conditions ODD (40-50%) Learning Conduct (10%) Disorders ODD (40-50%) (50-60%) Anxiety Disorders ADHD Anxiety (35%) Mood Disorders Mood Disorders Disorders (35%) ADHD Only (5-25%) (30-50%)

7 How common is ADHD? Prevalence of ADHD Prevalence of Medication Treatment for ADHD in Elementary School Children in Johnston County, NC 10% given a diagnosis of ADHD 7% were receiving ADHD medication treatment diagnosis and treatment varied by sex, race/ethnicity and grade 15% of boys vs 5% of girls given the diagnosis 9% of African American children 4% of Hispanic children 6.5% in grade 1 vs 13% in grade 5 11% of boys vs 3% of girls treated with medications 8% of Caucasian children 5% of African American children 2% of Hispanic children Roland, Umbach, et al. Prevalence of Medication Treatment for Attention Deficit Hyperactivity Disorder among Elementary School Children in Johnston County, NC. Am J Public Health.2002;92:

8 ADHD Toolkit Vanderbilt ADHD Score: Parent Report ADHD Subtype Score Inattentive (items 1-9) Hyper/Impuls (items 10-18) Combined (items 1-18) Performance (items 48-55) Total # positive symptoms Criteria / 9 6/9 pos. + 1 pos. imprmnt / 9 6/9 pos. + 1 pos. imprmnt / 18 12/18 pos. + 1 pos. imprmnt Meets DSM-IV Criteria YES YES YES NO NO NO / 8 YES NO Symptoms present > 6 months? Yes No Symptoms present to some degree < 7 years old? Yes No

9 COMORBIDITIES From Parent NICHQ Vanderbilt Oppositional-Defiant Disorder (questions 19-26; 4 of 8 symptoms with scores of 2 or 3 are positive AND a score of 4 or 5 on any of the 8 Performance Section items) Conduct Disorder (questions 27-40; 3 of 14 symptoms with scores of 2 or 3 are positive AND a score of 4 or 5 on any of the 8 Performance Section items). Anxiety / Depression (questions 41-47; 3 of 7 symptoms with scores of 2 or 3 are positive AND a score of 4 or 5 on any of the 8 Performance Section items).

10 Review Visits, Parent and Teacher Packets Visit packets: #1, 2, 3 Progress notes Vanderbilts for parents Parent training group handout (visit #2) Teacher Packets given at Visits #1, 2 Letters to teacher, Vanderbilts, envelope, release of information, teacher handout Parent Packets from Emily Center, given at Visit #2 Info on Emily Center and available resources National and local resource list Articles

11 Resident Responsibilities Visit #1 Review history form with parent / child Complete visit forms (H & P) Review and document cardiac risk factors Consult with attending Provide parent with Vanderbilt and Teacher packet #1 Schedule 2 nd visit

12 Resident Responsibilities Visit #2 Score Parent and Teacher Vanderbilts Complete Visit #2 form Consult with attending Discuss diagnosis with parent / child Discuss treatment regimen and /or referral to psychiatry Refer to Psychology - Parent Training Group Provide parent with Emily packet and Teacher packet #2 Schedule Visit #3

13 Resident Responsibilities Between Visits 2 and 3 Phone to parent once a week using phone script Document progress on medication Consult with attending Make any necessary changes to medication Remind parent of Visit #3

14 Resident Responsibilities Visit #3 Review and score Parent and Teacher followup Vanderbilts Complete Visit #3 form, including interim H&P Consult with attending Discuss diagnosis and further management with parent / child, including transfer back to PCP or ADHD Medication Management Clinic Attending dictates report for chart and for PCP

15 When to refer to Psychiatry At Visit #1 if: Suspect significant psychiatric disorder If other conditions make the child inappropriate for ADHD Diagnostic Clinic At Visit #2 if: If child does not meet criteria for ADHD, but there are other psychiatric concerns If child does meet ADHD criteria, but comorbidities are more impairing At Visit #3 if: Child fails medication trial or medication makes comorbidities worse

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