E-Resource September, 2015 Attention Deficit Hyperactive Disorder (ADHD) Attention Deficit Hyperactivity Disorder (ADHD) is the most common childhood behavioral health concern noticed in primary care. At times there have been controversy surrounding this topic because of concerns about overdiagnosis, misuse of medication, and the potential for abuse, ADHD treatment is often easily treated with prompt and clear clinical response. Following are some basic review and clinical guidelines. Diagnosis People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development: Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked). Often has trouble organizing tasks and activities. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Is often easily distracted Is often forgetful in daily activities. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person s developmental level: Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). Often unable to play or take part in leisure activities quietly. Is often "on the go" acting as if "driven by a motor". Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (e.g., butts into conversations or games) **See page 5 for the ADHD Symptom Checklist First Line Treatment/ Interventions: First line interventions for most behavioral health conditions in young children and adolescents include counseling and non-pharmacologic treatments. Behavioral parent training: Behavior-modification principles provided to parents for implementation in home settings including: Effective rewards for desired behaviors Structured home activity scheduling Consequences for undesired behavior Realistically increasing expectation for behavior mastery Behavior plans as part of a 504 Rehabilitation Act Plan or special education Individualized Education Program (IEP) under the other health impairment designation Pharmacologic Treatments/ Interventions: Stimulant medications are highly effective for most children in reducing core symptoms of ADHD. One selective norepinephrine reuptake inhibitor (atomoxetine) and selective2-adrenergic agonists (extended-release guanfacine and extended-release clonidine) have also demonstrated efficacy in reducing core symptoms. **See more on page 3 to review the Medication Algorithm About the Virtual Guidance Program JPS Health Network is proud to offer a new behavioral health clinical guidance resource to all primary care providers in our region. The JPS Behavioral Health Virtual Resource service offers: Telephone consultation with a behavioral health clinical team member Referral to community resources benefiting behavioral health patients Online reference library of behavioral health education materials Educational opportunities to increase provider understanding and comfort level in treating behavioral health conditions. Call 1-855-336-8790 or visit www.jpsbehavioralhealth.org for more information and to access a free virtual consultation for your patient
ADHD Medication Algorithm
Medication Algorithm for Attention Deficit Hyperactivity Disorder (ADHD) STAGE 1 Amphetamine or Methylphenidate 2 A different class of stimulant from that used in Stage 1 3 Atomoxetine May be used 1 st stage if: Patient or household member has history of substance abuse. May be used 2 nd stage if: Severe side effects to first stimulant used**. Continuation 4 Bupropion immediate release 5 Clonidine ** mood changes, > 5% weight loss compared to baseline, abnormal blood pressure, agitation, psychois Consultation or referral
ADHD Symptom Checklist
Attention Deficit/ Hyperactivity Disorder (ADHD) Symptom Checklist Child s name: Child s age: Today s date: Inattention Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is inappropriate for developmental level Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. Often has trouble keeping attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (loses focus, gets sidetracked). Often has trouble organizing activities. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). Is often easily distracted. Is often forgetful in daily activities. Hyperactivity / Impulsivity Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level Often fidgets with hands or feet or squirms in seat when sitting still is expected. Often gets up from seat when remaining in seat is expected. Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). Often has trouble playing or doing leisure activities quietly. Is often "on the go" or often acts as if "driven by a motor". Often talks excessively. Often blurts out answers before questions have been finished. Often has trouble waiting one's turn. Often interrupts or intrudes on others (e.g., butts into conversations or games). More information: http://www.cdc.gov/adhd 800-CDC-INFO, TTY: 888-232-6348; cdcinfo@cdc.gov
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5), Washington, D.C.: American Psychiatric Association American Psychiatric Association. Diagnostic criteria for attention deficit/hyperactivity disorder. Retrieved from: www.dsm5.org/proposedrevision/pages/proposedrevision.aspx?rid83 Sung V, Hiscock H, Sciberras E, Efron D. Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family. Arch Pediatr Adolesc Med. 2008; 162(4):336 342 Centers for Disease Control and Prevention. (2015). ADHD Symptoms Checklist. Retrieved from: www.cdc.gov/ ncbddd/adhd/materials.html