Diagnosis and Medical Management of ADD/ADHD How do we make the diagnosis of ADD/ADHD? We are very careful to be sure we have the diagnosis correct before considering treatment. In the past there were only parent and teacher assessment surveys available. But now we have a more objective method in the computerized McLean Motion and Attention Test developed at Harvard University. Commercially known as the Quotient Test, it is the only objective test of ADD/ADHD approved by the FDA. Combining the Vanderbilt Assessments (the American Academy of Pediatrics standard) and the Quotient Test we can be very certain we are not over-diagnosing this disorder. In addition, we have quantitative parameters that we can refer to later to measure the response to treatment. What is the typical Evaluation Schedule? Visit I - Initial History and Physical (45 minutes) Information is obtained about the child's symptoms and past medical problems that may be related to AD/HD, school performance, and behavior problems. A physical exam is done to determine the physical state of the child and if any neurological or developmental abnormalities arc present. Recent hearing and vision screens are requested from the PCP. The Vanderbilt Assessment for Teacher and Parents is given to the parent. The Teacher version is accompanied by a letter and instructions to the teacher(s) to fill it out and return it by mail or Fax. We do not want the evaluation shared with the child or the parent before the next meeting. For third grade and above, two teachers are selected in major subjects - one in humanities and the other in math or science. The Parent version is filled out by both parents if possible and brought in at the next visit. This second visit is scheduled for 3-5 days after the teachers have mailed their evaluations so we are certain to have all the evaluations available for scoring and review. In addition, the parent will be asked to schedule the McClean Motion and Attention Assessment (Quotient test) at the office of Lake Area Pediatrics (phone (936) 582-5620 in Montgomery. This test is only given on Tuesday, Wednesday and Thursday mornings. Your insurance will almost always reimburse for this test. This is a computer test that measures motion and attention to figures on the computer screen. The test for children age 6 through 12 lasts for 15 minutes while the adolescent test lasts twenty minutes. This is the first FDA-approved system for the objective measurement of hyperactivity, impulsivity and inattention as an aid in the assessment of ADHD. Finally parents are encouraged to get onto the web-site (www.conroeadhd.com) and read about the medications and other resource materials November 6, 2017 1
Visit 2- Quotient ADHD test (30 min) The Quotient ADHD test is given on Tuesday, Wednesday and Thursday mornings. Patients being evaluated for ADHD for the first time are required to take this test for diagnosis and for those already on medication to establish performance. Information on the Quotient test is on the website. Visit 3- Review of Quotient and Vanderbilt Assessments (30-45 min) Quotient and Parent and Teacher Vanderbilts are reviewed and it is determined if the child has enough factors to establish the diagnosis of AD/HD. If the diagnosis is confirmed we discuss the options for treatment including medications. A prescription may be dispensed at this time. All stimulants are Schedule II drugs and require a special license for dispensing and special rules for filling and re-filling. Usually the insurance companies will not allow more than 30 days at a time to be filled. A medication schedule is devised at this visit and a review of side effects. A chart is given to the parent to record side effects. The medications are almost always started on a Saturday at the lowest dose in order for the parent to be able to monitor side effects. The dose is increased at weekly intervals as needed to get the desired effect. Frequent visits are often needed to establish the correct dose for each child. Visit 4- First follow-up visit on medication (30 min) This visit usually occurs 10-14 days after starting the medications to monitor for adverse side effects, check blood pressure and heart rate and determine how well the adjusted dose is addressing the patient's problems. As long as the dose is being increased the patient is seen every two weeks. Once we are satisfied that a particular dose is effective the child will be monitored on that dose. Subsequent visits - Adjusting the dose These visits will be at least monthly or more frequent if the dose must be altered more often tor tuning or to decrease side effects. Once the dose is established with the desired result for at least two months these visits are stretched out. Subsequent visits - Maintaining the dose If the dose is not changed for two months and we are satisfied with the result, the child visits are only necessary every 3-6 months. After the child has been on a fixed dose of medication for 6 months, they will progress to semi-annual visits -- only be required every about every 6 months-- in the Fall (September or October) and again in the Spring (February or March). November 6, 2017 2
How do we treat the patient with the diagnosis of ADD/ADHD? Most of the medications used to treat ADD/ADHD are stimulants and derivatives of methylphenidate (Ritalin-like) or dextroamphetamine (Adderall-like). There has been more than half a century of experience in the use of these preparations. We know their benefits and there side effects well. Some people are more sensitive than others. There is no simple weight-based dose. We have some adolescents on tiny doses with good effect and some kindergartners that need to be increased to very high doses to get the same beneficial effects. It depends on their genetics and how the liver metabolizes the drugs. The side effects of these medications are discussed below. In the past several years a few non-stimulant medications have come out like Strattera, Intuniv, and Kapvay. In most cases, these medications have not proven as effective as the stimulants. They are used in special cases where the stimulants are not beneficial or when not tolerated well or to supplement. Once the diagnosis has been established, the parent must decide if they wish to treat the ADD/ADHD. The treatment is the same for either or both conditions. Most children will have only ADD, but many have a combined ADD with hyperactivity (ADHD). Very few have ADHD alone. Medications usually prescribed include: Ritalin derivatives: Focalin XR Concerta Ritalin Capsule (sprinkled) Tablet Tablet Adderall derivatives: Vyvanse Adderall XR Capsule (may be dissolved in water or chewable) Capsule (sprinkled) Check with your insurance company to see what they cover and what you need to pay. These medications can be expensive and are used for 10-12 months out of the year. How do we determine the dose and manage the patient? We start a patient on the lowest dose possible of any of the stimulant meds in order to avoid any side effects. And these meds are always started on a weekend morning when the parent is available to assess their child s response. If there are no adverse side effects noted by the parent by Sunday evening, it is recommended that they may take the medication on Monday before going to school. We try to start meds that are long-acting to avoid having to give a dose in the middle of the day. This avoids disrupting the child s November 6, 2017 3
school schedule and the stigma of having to take medications at school. Often we see no response to the medication at the very low doses in the first 1-2 weeks. But that is more desirable than having an adverse effect. We usually increase the dose no quicker than one step per week. For instance, for Focalin XR we would start at 5 mg the first week and if no adverse effects and no significant improvement in symptoms after a week, we would increase to 5 mg x 2 (10 mg). This is called titration. This would go on until we are getting the result we wish to see (usually only 2-3 weeks). The result sought is a decrease in ADD/ADHD symptoms like decreased excitability, impulsivity, fidgeting, disturbing others and an increase in attentiveness evidenced by improved handwriting, the ability to finish assignments in class and at home, and improved grades. Dr. Robinson will develop a medical management calendar with the parent or guardian with clear indication of dose and date to be given. The most important part of this calendar is the part that indicates when the parent should contact the doctor to report on his/her progress. These dates will be clearly indicated. It is usually Tuesday and Friday each week by phone or Portal message. The Friday contact is important to discuss whether we should increase the dose to the next level the following day (Saturday AM). The next office visit will usually be required two weeks after starting medications. Once this calendar is reviewed, the parent will be asked to sign a contract agreeing that they understand the dosage regimen and the requirement to report according to the schedule. If the parent fails to contact the doctor as agreed, the titration will be delayed or the patient may be discontinued from the protocol. At no time should a parent take it on themselves to increase the dose without the doctor s consent. The parent can stop it at any time. These medications are Controlled Substances and highly regulated. More discussion in this regard to follow. What are the typical side effects of stimulants? Since these medications are stimulants, they can cause the same side effect as any stimulant like caffeine, tea, Coca-cola, or the popular energy drinks. In order of decreasing frequency they may include: 1) Appetite loss Usually at lunch time when the blood level is highest. This can be minimized by drinking a protein shake at lunch like Boost or Ensure. 2) Stomachache Usually just after taking the medication in the morning at the onset of therapy. It is recommended to always take these meds with food and best with a high-protein meal (like eggs, meat, cheese, yogurt, or Instant Breakfast). 3) Trouble sleeping which is often part of the ADHD (not the medication effect) 4) Anxiety, increased worry, emotional lability (cries more easily) 5) Headache 6) Picking at fingers, nail biting, or lip chewing If an adverse side effect is noted that is concerning, the parent should not administer the next day s dose. In most cases, these medications are rapidly cleared from the body by the same afternoon. If concerned, call the office number on the weekend or November 6, 2017 4
Dr. Robinson on Monday morning (he is the on-call doctor most weekends). On the other side of that, the beneficial effects of the medication can be noted within hours if the dose is correct for that child. How do we get the medications refilled? As mentioned above, these medications are controlled substances (Schedule II) just like codeine, cocaine, oxycodone, morphine and methadone. We must follow a very rigid set of regulations in order to have the license to prescribe them. The reason they are Schedule II is because of the potential for abuse by persons seeking a high. ADD/ADHD patients do not react that way. The prescriptions can be written on a special form that is supplied by the Texas State Board of Pharmacy and each one is traced monthly. However, Dr. Robinson has the ability to write all his prescriptions electronically even the controlled substances from my office medical software. The script goes directly to the pharmacy for pick-up the same day. No pick-up at the office is necessary. The Rx must be obtained from the pharmacy within 21 days of transmission. When a refill is needed the parent must send Dr. Robinson a request message (via the Portal) and that request is documented in the chart. Refills are usually processed in the evening or sooner during the week. Dr. Robinson will send a portal message confirming that the Rx is ready to pick up at the pharmacy. This works much better than phoning in a request and is the reason we prefer all these patients be on the Portal. Do not wait until there are only two pills left to request a refill! I attest that I have read this information, understand it and agree to comply by the conditions outlined above. Signed Date Printed Name November 6, 2017 5