I. Diagnostic Considerations (Assessment)...Page 1. II. Diagnostic Criteria and Consideration - General...Page 1

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1 SUTTER PHYSICIANS ALLIANCE (SPA) 2800 L Street, 7 th Floor Sacramento, CA SPA PCP Treatment & Referral Guideline Attention Deficit/Hyperactivity Disorder in Children and Adolescents Developed March 1, 2003 Revised September 21, 2006 Reviewed October 20, 2010 I. Diagnostic Considerations (Assessment)...Page 1 II. Diagnostic Criteria and Consideration - General...Page 1 III. Diagnostic Criteria 2 Groups of Symptoms...Page 1-2 IV. ADHD 3 Types.....Page 3 V. Treatment Intervention Overview...Page 3 VI. FDA Approved Medications.....Page 3 VII. FDA Warnings and Recommendations......Page 3

2 SPA PCP Treatment and Referral Guidelines ADHD In Children and Adolescents Reviewed 11/24/2008 Page 2 of 4 I. Diagnostic Considerations: Assessment - Unlike many other syndromes, children with ADHD may not display symptoms in the Doctors office. It is necessary to collect information from: parents, school and other treating professionals to do a complete assessment. A) Interview with parents to obtain key symptoms, age of onset, stability of symptoms B) Academic, medical, psychiatric and substance abuse history along developmental lines C) School evaluation to verify symptoms D) Child diagnostic interview: a) MSE b) Child s own description of problems E) Psychometric interview: standard ratings scale: Vanderbilt ADHD checklist F) Screen for comorbid/contributing conditions (substance abuse, learning disabilities, conduct disorders, mood disorders, neurologic problems/history, development (IQ) problems G) Complete P.E., Neuro exam in past year (rule out seizure disorder with soft neurological signs) H) Prevalence: 3-7% of school-aged children a) Boys: Girls 3:1 (girls and non-white boys are often not hyperactive) II. Diagnostic Criteria and Considerations General A) Persistent pattern of inattention and/or hyperactivity/impulsivity more frequent and severe than is typically observed in individuals with a comparable level of development and intellectual ability B) Some symptoms which cause impairment were present before 7 years old C) Symptoms present in 2 or more settings D) Clear evidence of clinically significant impairment in social OR academic functioning E) Notes: a) A positive family history is a predictor b) Simple hyperactivity (without the full spectrum of 6 symptoms or 6 months plus maladaption) is not by itself ADHD c) Girls and non-white boys often do not show hyperactivity but do still have the syndrome III. Diagnostic Criteria 2 Groups of Symptoms - There are 2 groups of symptoms: The patient must exhibit 6 or more for a minimum of 6 months: A) Inattention Domain a) Failure to give close attention to detail b) Difficulty sustaining attention c) Failure to listen when spoken to directly d) Failure to follow through on instructions e) Difficulty organizing tasks to completion f) Avoids tasks that require sustained mental effort g) Loses things necessary for tasks or activities h) Easily distracted by extraneous stimuli stimulus bound i) Forgetful in daily activities B) Hyperactivity Impulsivity Domain a) Fidgets with hands or feet, squirms in seat b) Leaves seat in situations where remaining seated is expected c) Runs or climbs inappropriately

3 SPA PCP Treatment and Referral Guidelines ADHD In Children and Adolescents Reviewed 11/24/2008 Page 3 of 4 d) Has difficulty playing or engaging in leisure activities quietly e) On the go, driven like a motor f) Talks excessively g) Blurts out answers before questions completed h) Has difficulty awaiting turn i) Interrupts or intrudes on others IV. ADHD Three Types ADHD is divided into 3 types according to the presence or absence of the symptoms in the categories. A) Predominantly inattentive B) Predominantly hyperactive impulsive C) Combined both sets of symptom domains occur V. Treatment Intervention: Overview A) An alliance with parents, school and patient promotes treatment success B) Educate parent and family members about the disorders and its symptoms C) Behavioral modification and psychosocial interventions with a multi-model approach is essential, including modifications, face-to-face follow ups. D) Monitor progress by assessing with Vanderbilt scale, monitor weight, height, blood pressure and pulse. E) Reduction of target symptom severity & pervasiveness F) Improvement in family and peer relationships G) Reassess for learning disabilities and other psychiatric conditions if poor response to medications. VI. VII. FDA Approved Medications A) Stimulants and Atomoxetine (Strattera) B) Refer to Treatment Options for ADHD (enclosed) C) Maximize dose when no side effects (do not exceed recommended limits) FDA Warnings and Recommendations A) The FDA requires a "Black Box Warning" on the use of Atomoxetine used in children and adolescents regarding the potential for increased suicidal thinking and behavior that can occur during the early onset phase of treatment. B) Regarding stimulant medication use. The FDA warns of the risk for serious cardiovascular events such as sudden death, hypertension, and other cardiovascular conditions and recommends that the treating professional appropriately assess for cardiovascular risk in patients being treated with stimulant medications. C) Screening EKG remains controversial.

4 SPA PCP Treatment and Referral Guidelines ADHD In Children and Adolescents Reviewed 11/24/2008 Page 4 of 4 APPROVAL: SMF / SPA Medical Director Behavioral Health Medical Director November 10, 2010 November 10, 2010 Date Date Revision / Approval Summary: SMF QM Committee SPA Steering Committee Date: _11/10/2010 Date: FYI

5 BRIGHT FUTURES TOOL FOR PROFESSIONALS I N S T R U C T I O N S F O R U S E Vanderbilt ADHD Diagnostic Teacher Rating Scale INSTRUCTIONS AND SCORING Behaviors are counted if they are scored 2 (often) or 3 (very often). Inattention Requires six or more counted behaviors from questions 1 9 for indication of the predominantly inattentive subtype. Hyperactivity/ Requires six or more counted behaviors from questions impulsivity for indication of the predominantly hyperactive/impulsive subtype. Combined subtype Requires six or more counted behaviors each on both the inattention and hyperactivity/impulsivity dimensions. Oppositional Requires three or more counted behaviors from questions defiant and conduct disorders Anxiety or Requires three or more counted behaviors from questions depression symptoms The performance section is scored as indicating some impairment if a child scores 1 or 2 on at least one item. FOR MORE INFORMATION CONTACT Mark Wolraich, M.D. Shaun Walters Endowed Professor of Developmental and Behavioral Pediatrics Oklahoma University Health Sciences Center 1100 Northeast 13th Street Oklahoma City, OK Phone: (405) , ext mark-wolraich@ouhsc.edu REFERENCE FOR THE SCALE S PSYCHOMETRIC PROPERTIES Wolraich ML, Feurer ID, Hannah JN, et al Obtaining systematic teacher reports of disruptive behavior disorders utilizing DSM-IV. Journal of Abnormal Child Psychology 26(2): The scale is available at vanderbilt.edu/vchweb_1/rating~1.html. 54

6 BRIGHT FUTURES TOOL FOR PROFESSIONALS Vanderbilt ADHD Diagnostic Teacher Rating Scale Name: Grade: Date of Birth: Teacher: School: Each rating should be considered in the context of what is appropriate for the age of the children you are rating. Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often 1. Fails to give attention to details or makes careless mistakes in schoolwork Has difficulty sustaining attention to tasks or activities Does not seem to listen when spoken to directly Does not follow through on instruction and fails to finish schoolwork (not due to oppositional behavior or failure to understand) 5. Has difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustaining mental effort 7. Loses things necessary for tasks or activities (school assignments, pencils, or books) 8. Is easily distracted by extraneous stimuli Is forgetful in daily activities Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected 12. Runs about or climbs excessively in situations in which remaining seated is expected 13. Has difficulty playing or engaging in leisure activities quietly Is on the go or often acts as if driven by a motor Talks excessively Blurts out answers before questions have been completed Has difficulty waiting in line Interrupts or intrudes on others (e.g., butts into conversations or games) Loses temper (continued on next page) 55

7 Vanderbilt ADHD Diagnostic Teacher Rating Scale (continued) Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often 20. Actively defies or refuses to comply with adults requests or rules Is angry or resentful Is spiteful and vindictive Bullies, threatens, or intimidates others Initiates physical fights Lies to obtain goods for favors or to avoid obligations (i.e., cons others) Is physically cruel to people Has stolen items of nontrivial value Deliberately destroys others property Is fearful, anxious, or worried Is self-conscious or easily embarrassed Is afraid to try new things for fear of making mistakes Feels worthless or inferior Blames self for problems, feels guilty Feels lonely, unwanted, or unloved; complains that no one loves him/her Is sad, unhappy, or depressed PERFORMANCE Problematic Average Above Average Academic Performance 1. Reading Mathematics Written expression Classroom Behavioral Performance 1. Relationships with peers Following directions/rules Disrupting class Assignment completion Organizational skills