ADHD Child and Adolescent Clinical Guideline

Transcription

1 ADHD Child and Adolescent Clinical Guideline ADHD Concern Identified Hyperactive, Impulsivity. Severity and of symptoms. functional impairment rating scales, m amily HX ADHD Diagnosis Only? Develop Treatment Plan: Medication Assess/Mgmt. Family Psycho-Education Behavior Assess/Mgmt. School Based Behavioral Management, IEP Ancillary Treatments: Speech, Occupational Tx, etc. Modify for comorbid Refer to CHADD Behavior Assess/Management: Child Behavioral Assessment, Family Assessment and Education on Behavior Mgmt. Strategies Medication Assess/Management: Physical Exam, Blood Pressure, Ht & Wt, Review interactions with other prescribed s Ongoing care & Reevaluation If symptoms improve follow up at least 2x per year for ADHD issues If no improvement reevaluate to confirm diagnosis and reconsider plan and/or adherence issues. Medication Maintenance: If new RX two additional visits within next 9 months Select Medication for NO Other Dx MDD, Anxiety, Autism, Comorbid with ADHD? Stimulant n-stimulant Alternatives * See AAP process-of-care algorithm (Supplemental Table 3) Return visit Medication within 30 days of visit, Titration/Replacement, Augmentation until stable. Treatment plan or referral for American Academy of Child and Adolescent Psychiatry (AACAP) Charach A, et,al, Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Comparative Effectiveness Review. 44. (Prepared by the AHRQ Publication. 12-EHC003-EF. Rockville, MD: Agency for Healthcare Research and Quality. October Available at: final.cfm.pelham,we, Fabiano, GA: Evidence Based Psychosocial Treatments for ADHD. JCCAP, 37(1), , 2008 Adopted May Revised 9/2008, 1/2011, 11/2011, 11/2013, 12/2015. Reviewed Annually.

2 Adult Substance Abuse Initial Assessment Clinical Guideline Health professional screens at the initial visit and episodically thereafter using a structured instrument. Recommended instruments include: 1.Alcohol Use Disorders Identification Test (AUDIT) 2.Drug Abuse Screening Test (DAST) 3.(CAGE ) Substance Abuse Screening Tool; name is derived from the four questions of the tool: Cut down, Annoyed, Guilty, and Eye-opener Member has overt symptoms of withdrawal, or these are reasonably expected with abstinence If screening is positive, obtain a full history of drug and ETOH use If screening is negative and there are no suspicions of withholding information, then no further action is needed. However, in circumstances where there is reasonable doubt as to accuracy of the screening results, confirmation with a significant other is urged to gain confidence in the screening result Evaluate for appropriate level of care for detox management. Plan for compliance with HEDIS IET for follow up after detox is complete If screening is positive and results of evaluation confirm current DSM diagnosis of abuse or dependencies. Plan an initial visit for SUD within 14 days, and 2 follow-up visits within 30 days of the initial visit (HEDIS IET Measure) If screening is positive, but a current DSM diagnosis of abuse or dependence is not met, employ Screening, Brief Intervention and Referral for Treatment (SBIRT) for problem drinking Currently engaged in SUD t currently engaged in SUD Assess for compliance with and assess for Medication Assisted Treatment Assess for appropriate level of rehabilitation and Medication Assisted Treatment and refer Continue regular visits and if applicable, Medicated Assisted Therapy compliance Screen: Periodically and routinely screen patients for substance use as well as for substance use dependence. Screening requires only two to four minutes. Use the DAST to screen for drug use. This tool profiles the frequency of substance use behavior. Use the AUDIT-C alone or in combination with the CAGE to screen for alcohol use. AUDIT-C is designed to identify hazardous drinking and focuses on recent drinking behaviors. The CAGE is better at detecting alcohol dependence. These screening tools and scoring instructions can be found at index.html a site developed and maintained by Dartmouth Medical School. Information about the Audit-C can be found at Definitions: The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90% of America s health plans to measure performance on important dimensions of care and service. Initiation and Engagement of Alcohol and Other Drug Dependence (IET) is a HEDIS measure. Members meet the measure by initiating within 14 days of AOD diagnosis and have two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse and dependence on alcohol and illicit drugs. References: American Society of Addiction Medicine (ASAM) criteria 3rd Edition, 2013 ASAM: research-/screening-andassessment SAMHSA: prevention/. Adopted 12/05. Revised 6/06, 4/08, 12/09. 04/11, 01/12, 8/14 Reviewed annually

3 Bipolar Disorder Treatment Guideline-Acute Episode Risk factors to assess should include: Suicide/Homicide Risk Psychosis/Delirium Substance Abuse Medical Conditions Meets criteria for Bipolar Disorder Assess for risk factors and level of care Refer to appropriate level of care based on risk level Does patient have manic or mixed symptoms? Taking mania inducing? Reduce or stop the Consider change or addition of Responding to? Reassess as needed based on LLOC and severity If started on a atypical antipsychotic please obtain baseline lipid panel and blood glucose or HbA1c Initiate or adjust with appropriate (Refer to med algorithm) If in higher level of care symptom reduction allows discharge to outpatient care When in outpatient care reassess every 1-2 weeks for 6 weeks Continued improvement Assess adherence, and needed psychosocial interventions Consider add/ change of and psychosocial intervention Continue current and monitor at least monthly for 3 months Maximal level of improvement reached If remains on an atypical antipsychotic please repeat lipid panel and blood glucose or HbA1c Source: The World Federation of Societies of Biological Psychiatry (WFSBP ) Adapted from the National Guideline Clearing House and the National Institute of Mental Health (NIMH) Reassess diagnosis, Consider ECT Obtain consult Continue to Maintenance Guideline Guidelines for the Biological Treatment of Bipolar Disorders: Update 2012 on the long-term of bipolar disorder Adopted: January Revised: 1/2012, 11/2013, 03/2015 Reviewed Annually.

4 Bipolar Disorder Maintenance Episodes Guidelines Number of prior episodes First episode-mania Second episode-one with Mania Third or more episode-at least one hypomania 1 st degree family history and/or severe episode 1 st degree family history and/or severe episode Maintenance may not be needed Consider maintenance Maintenance indicated Maintenance initiated % Reduction of pre maintenance episodes Based on s used follow recommended health screenings and monitoring such as blood glucose with SGA antipsychotics, kidney and thyroid function for Lithium Continue with preventive agent (PA) Continue with PA and consider combination therapy Consider new PA and combination therapy Switch to new PA For specific maintenance selection and monitoring please go to: The World Journal of Biological Psychiatry, 2013; 14: Table VIII page 170.

5 Major Depression Guideline for Initial Outpatient Treatment of Adults Perform a diagnostic evaluation to include a full HPI (including Why w? ), previous psychiatric tx. Medical history, current and past s, family history, substance use, etc. Clinical conforms to current DSM criteria for MDD Assess for most appropriate LOC, accounting for safety/risk issues Acute Phase: The goal of tx. is Recovery = absence of symptoms and a return to full function. 1 st F/U visit within 21 days At least 3 F/U visits within 84 days Screen for SUD. Rule out medical conditions DSM Criteria Met? Consider other diagnoses, e.g.: dysthymia, bipolar, Substance use, etc. Medication Management: Past or family HX of response Side Effect Profile Generic vs. Brand Maximize dose, if tolerated Adherence education Psychotherapy: Cognitive Behavioral, Interpersonal, supportive, problem solving, social skills, behavioral & psychodynamic therapies Communicate findings and plan to referring clinician. Evaluate response & reassess progress with meds & psychotherapy at least monthly. If moderate improvement is not present within 8 weeks, review med adherence, need for med change, psychotherapy change. Recovery or significant response? Maintenance Phase: Continue Medication at optimal dose. 1 st episode 6 months 2 nd episode 2 to 3 years 3 rd episode indefinitely Consider these actions: After 8-12 weeks of limited response, a new trial is indicated Review diagnosis Evaluate for substance use co-morbidity Begin augmentation/ combination strategy * Consider ECT Referral for 2 nd opinion * If second generation antipsychotic is started obtain baseline lipid and blood glucose levels and retest in 3 months. Test yearly if long term use is indicated. Post Maintenance Phase: Decision is whether to resume full dose, or less. Taper Med? Observe carefully for Sx recurrence. If taper is successful and further visits are not indicated, Educate patient & family re: relapse risk & return of Sx. Consider handouts to reinforce learning Maintain. Management visits every 2-3 months. If stability remains, consider referral to PCP for continued management and communicate with PCP Communicate current status to PCP or referring physician Sources: American Psychiatric Association Practice Guideline for Major Depressive Disorder In Adults: Santaguida P, MacQueen G,Keshavarz H, Levine M, Beyene J, Raina P. Treatment for Depression After Unsatisfactory Response to SSRIs. Comparative EffectivenessReview. 62. (Prepared by McMaster University Evidence-based Practice Center) Agency for Healthcare Research and Quality; April npharmacologic Interventions for Treatment-Resistant Depression in Adults, Comparative Effectiveness Review,. 33, prepared by the RTI International University of rth Carolina Evidence-based Practice Center, AHRQ, September Developed and adapted by New Directions Behavioral Health. Adopted 5/00. Revised 2/02; 6/05, 6/06, 1/11, 12/12, 7/13, 11/13, 2/15. Reviewed annually.