Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit/Hyperactivity Disorder in Children and Adolescents

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1 Prepared for your next patient. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit/Hyperactivity Disorder in Children and Adolescents Mark L. Wolraich, MD, FAAP CMRI/Shaun Walters Professor of Pediatrics University of Oklahoma Health Sciences Center TM

2 Disclaimers Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics. Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenter has complete and independent control over the planning and content of the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenter s comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA approved product label.

3 Learning Objectives Participants will be able to report on the major changes in the revised attentiondeficit/hyperactivity disorder (ADHD) guideline. Participants will be able to obtain and use appropriate behavior rating scales. Participants be able to describe the importance of considering ADHD as a chronic condition. Participants will be aware of the variations in treatment recommended for preschool age children and adolescents.

4

5 ADHD Guideline Recommendations 1. The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. B/strong recommendation

6 Prevalence of ADHD in Children Centers for Disease Control and Prevention/National Health Care Surveys,

7 Prevalence and Medication Use ADHD prev ADHD on meds ADHD not on meds ADHD diagnosed on meds

8 ADHD Guideline Recommendations 2. To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) criteria have been met (including documentation of impairment in more than 1 major setting) with information obtained primarily from parents/guardians, teachers, and other school and mental health clinicians involved in the child s care. The primary care clinician should also rule out any alternative cause. B/strong recommendation

9 Evaluation Identify core symptoms. Assess impairment. Identify possible underlying or alternative causes. Identify co occurring (co morbid) conditions.

10 DSM IV Core Symptoms of Inattention Manifestations of the following symptoms must occur often:* Inattention Careless Difficulty sustaining attention in activity Doesn t listen No follow through Avoids/dislikes tasks requiring sustained mental effort Can t organize Loses important items Easily distractible Forgetful in daily activities *Must have 6 or more symptoms for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Arlington, VA: American Psychiatric Association; 2000

11 DSM IV Core Symptoms of Hyperactivity Impulsivity Manifestations of the following symptoms must occur often:* Hyperactivity Squirms and fidgets Can t stay seated Runs/climbs excessively Can t play/work quietly On the go / driven by a motor Talks excessively Impulsivity Blurts out answers Can t wait turn Intrudes/interrupts others *Must have 6 or more symptoms for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Arlington, VA: American Psychiatric Association; 2000

12 Assess Function Academic performance Peer relations Sibling relations Parent relations Community activities

13 Clinical Global Impression Scale TM

14 DSM IV ADHD Diagnostic Criteria List of core symptoms must be present for past 6 months. Some symptoms need to be present before 7 years of age. Some impairment from symptoms must be present in 2 or more settings (eg, school and home). Significant impairment (social, academic, or occupational) must be present. Other mental disorders need to be excluded as the cause of the core symptoms. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Arlington, VA: American Psychiatric Association; 2000

15 Inattention or Hyperactive/Impulsive Problems Children who do not meet the criteria of ADHD still may have some symptoms of inattention and/or hyperactivity/impulsivity fitting the category in the Diagnostic and Statistical Manual for Primary Care (DSM PC) of inattention and/or hyperactivity/impulsivity. Use of the chronic illness model and behavioral interventions are appropriate, but medications are not. American Academy of Pediatrics. In: Wolraich ML, Felice ME, Drotar D. The Classification of Child and Adolescent Mental Diagnosis in Primary Care. Elk Grove Village, IL: American Academy of Pediatrics; 1996

16 Preschool Age Diagnostic Issues The same criteria are pertinent for preschool age children, but it is more difficult to find qualified observers of these children. Enroll the child in a program and/or have the parents participate in a parent training program. Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):

17 Adolescent Diagnostic Issues It is much more difficult to get adequate observers, as both parents and teachers have less opportunity to observe. The risk of substance abuse is higher and must be ruled out before a diagnosis can be made. The occurrence of co morbid conditions, particularly anxiety or depression, is more frequent. Wolraich ML, Wibbelsman CJ, Brown TE, et al. Attention deficit/hyperactivity disorder in adolescents: a review of the diagnosis, treatment and clinical implications. Pediatrics. 2005;115:

18 Diagnostic Process Use of ADHD specific rating scales is a clinical option in the evaluation of ADHD. Use of broad band rating scales is not recommended in diagnosing ADHD although they may be useful for evaluating for coexisting conditions.

19

20 Websites for the Vanderbilt Scales The University of Oklahoma College of Medicine American Academy of Pediatrics Pediatric Care Online Tools/Keywords/N/NICHQ

21 ADHD Guideline Recommendations 3. Evaluation of a child for ADHD should include assessment for coexisting conditions, including emotional, developmental, and physical. B/strong recommendation

22 Co morbidity: Conditions Commonly Co occurring with ADHD Disruptive behavior disorders Oppositional defiant disorder Conduct disorder Depressive disorders Anxiety disorders Cognitive disorders Learning disabilities Language disorders Motor disorders Developmental coordination disorder Tic disorders (Tourette's)

23 ADHD Guideline Recommendations 4. The primary care clinician should establish a treatment program that recognizes ADHD as a chronic condition and a child with ADHD as a child/adolescent with special health care needs who needs a medical home. B/strong recommendation

24 Methylphenidate therapy bout length by patient age Miller AR, Lalonde CE, McGrail KM. Children s persistence with methylphenidate therapy: a population based study. Can J Psychiatry. 2004;49(11):

25 Treating ADHD as a Chronic Condition Educate parents and patients about ADHD. Develop a partnership with the family. Develop a management plan with specific targeted goals. Include the teachers if at all possible. Requires ongoing monitoring and anticipation of developmental changes.

26 ADHD Guideline Recommendations 5. Recommendations for treatment of children and youth with ADHD vary depending on the patient s age:

27 Preschool aged Children (4 5 Years of Age) A. Prescribe evidence based parent and/or teacher administered behavior therapy as the first line of treatment. A/strong recommendation and May prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate to severe continuing disturbance in the child s function. B/recommendation

28 Preschool Age Treatment Issues While stimulant medications are appropriate for preschool age children based on recent research, given that a third of the children in a multi site study improved on behavioral interventions alone, it is more appropriate to initiate a parent training program first before utilizing medication and only treat the more severe cases. Preschool age children frequently have a slower metabolism of the medications and can start at a lower dose and titrated at a slower rate. Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):

29 Elementary School aged Children (6 11 Years of Age) B. Prescribe FDA approved medications for ADHD. A/strong recommendation and/or Evidence based parent and/or teacheradministered behavior therapy as treatment for ADHD. Preferably both. B/recommendation

30 Adolescents (12 18 Years of Age) C. Prescribe FDA approved medications for ADHD with the assent of the adolescent. A/strong recommendation and May prescribe behavior therapy as treatment for ADHD. C/recommendation Preferably both.

31 Non Stimulants Atomoxetine is a highly specific norepinephrine reuptake inhibitor. Extended release guanfacine and clonidine are alpha 2 adrenergic agents.

32 ADHD Guideline Recommendations 6. The primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects. B/strong recommendation

33 Summary Children from preschool age through adolescent age can be diagnosed and treated for ADHD. Both medications (stimulants, selective norepinephrine reuptake inhibitors and alpha adreneric agents) and behavior therapy are effective and safe treatments for ADHD. Effective treatments require appropriate titration and ongoing monitoring to remain effective.

34 Caring for Children With ADHD A Resource Toolkit for Clinicians, 2nd Edition This comprehensive ADHD resource provides a full set of tools for assessment and diagnosis, treatment and medication, monitoring and follow up, parent education and support, and coding and payment. Included are more than 40 practice tested tools many in English and Spanish on one convenient CD ROM. The ADHD toolkit components have been evaluated and refined based on input from the American Academy of Pediatrics Quality Improvement Innovation Network (QuIIN). For more information or to order visit the AAP bookstore at

35 Additional ADHD Resources on Pediatric Care Online ( Forms & Tools Tools/Keywords/A/ADHD Patient Handouts AAP/Keywords/A/ADHD AAP Textbook of Pediatric Care Textbook of Pediatric Care/Topics/A Point of Care Quick Reference of Care Quick Reference/Topics/A

36 For more information On this topic and a host of other topics, visit: Pediatric Care Online is a convenient electronic resource for immediate expert help with virtually every pediatric clinical information need. Must have resources are included in a comprehensive reference library and time saving clinical tools. Haven't activated your Pediatric Care Online trial subscription yet? It's quick and easy: simply follow the steps on the back of the card you received from your Mead Johnson representative. Haven't received your free trial card? Contact your Mead Johnson representative or call 888/ today.

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