Download ADHD Part 1 ADHD Board Content Specifications: Understand the

ADHD Part 1
ADHD Board Content Specifications:
 Understand the role of rating scales & questionnaires in the assessment of
disruptive behaviors (ie Vanderbilt, Conners)
o FYI- Vanderbilt made for elementary evaluation- no normative data
for adolescents or young children
 Understand the utility of behavior modification approaches in the overall
management of children with learning, developmental, and behavioral
problems
 Know the long-term outcome for children with ADHD as adolescents & adults
 Know the medications in treating ADHD
 Know the side effects of medications used to treat ADHD, the
contraindications to their use, and the potential for their abuse
 Know the common conditions occurring in concert with oppositional defiant
or conduct disorder (eg ADHD, learning difficulties)
Board Questions:
1. A 7 y/o girl is having behavioral problems in school. Her academic skills are
strong, but she is impulsive and has difficulty staying on task and remaining
quiet while the teacher is talking. When the students line up, she pushes to
be at the head of the line. At home, her parents have problems getting her to
comply with their requests. She needs frequent reminders to sit down & do
her homework. Of the following, the MOST appropriate next step is to:
a. Begin a trial of stimulant medication
b. Complete Vanderbilt questionnaires
c. Have the parents institute a token economy behavior plan
d. Obtain a thyroid function test
e. Refer the child for psychoeducational testing
2. An 8 y/o boy in your practice has ADHD and learning issues. He currently is
receiving specialized educational services and methylphenidate for his
attention difficulties and hyperactivity. He does well with the structure that
is in place at school, but has issues with the compliance at home when
completing his homework. His parents seek guidance in establishing a
behavioral modification approach for him at home. Of the following, the
BEST intervention is:
a. Extinction
b. Habit reversal
c. Spanking
d. Stress anxiety reduction procedures
e. Token Economy
3. A 17 y/o boy comes to your office for medication management of his
attention-deficit/hyperactivity disorder (ADHD). He explains that his is
considering stopping his medication before his last year in high school. His
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parents are upset because they are fearful that his academic success with
diminish and that he may make poor social choices. His parents ask about
the long-term outcome for ADHD. Of the following, the MOST appropriate
response is that:
a. Certain features of ADHD (risk taking, fast-paced approach, outgoing
style) may be advantageous in some occupations
b. Longitudinal studies have not found elevated anxiety or mood
disorders among adults who have ADHD
c. Males who have ADHD have a greater ability to handle stressful
situations
d. More than 75% of children who have ADHD no longer have
inattention or have the need for stimulant medication in adulthood
e. Studies have not found a higher rate of divorce among adults that
have ADHD
4. An 8-year-old boy is having attention difficulties in his 3rd grade classroom.
He has undergone psychoeducational testing & has not had a learning
disability identified. His parents & teachers have completed Vanderbilt
rating forms, and the results are significant for inattention & impulsivity.
You are considering starting the child on medication to treat his attentiondeficit/hyperactivity disorder. Of the following, the MOST significant
historical information that would affect your decision to start treatment with
a stimulant medication is:
a. Absence epilepsy in his 6 y/o sister
b. Bipolar disorder in his paternal uncle
c. Mild motor tic in the child
d. Myocardial infarction in the paternal grandfather at the age of 65
e. Sudden death of his 15 y/o brother while playing basketball
5. An 8 y/o comes to your office because of academic issues at school. He is
refusing to do his homework and cries when his parents attempt to assist
him. He complains that schoolwork is too hard and that he has trouble
paying attention. Teachers report that he is very active & has difficulty
remaining in his seat. The boy is undergoing psychoeducational testing. His
parents are working with a behavioral therapist, but still find his behavior to
be challenging. They come to your office for guidance as they await the
results of the evaluation. On physical exam, you note him to be fidgety with
no evidence of motor tics. He is upbeat when discussing his recent sleepover
with friends, but he becomes distressed when the focus of the discussion
shifts to his school performance. Of the following, the BEST next step would
be an evaluation for:
a. Attention-deficit/hyperactivity disorder
b. Central auditory processing disorder
c. Conduct disorder
d. Depression
e. Tourette disorder
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Answers:
1. PREP 2012, #116: B
2. PREP 2012, #169: E
a. Token Economy: providing rewards or privileges for the child’s
positive behavior and losing those for negative behaviors
b. Extinction: denial of all attention after a child engages in a negative
behavior, which can be an effective approach but often causes a
transient increase in negative behavior
c. Do not recommend spanking, habit reversal (Not demonstrating habit
disorder)
3. PREP 2012, #222: A
a. 75-85% of affected children continue to have symptoms of impulsivity
& low attention into teenage years & adulthood
b. Longitudinal studies show elevated anxiety & mood disorders , in
males a decreased ability to handle stress, higher divorce rate
4. PREP 2012, #238: E
5. PREP 2013, #56: A
a. Among children with disruptive disorders, ADHD occurs 10 as often
2011 Clinical Practice Guidelines
See attached guidelines for details/explanation of each key point as well as the
supplement for additional information on medications, algorithms, &
implementation
Key action points:
1. Initiate evaluation for ADHD in child 4-18 who presents with academic or
behavioral problems & symptoms of inattention, hyperactivity, or impulsivity
(GRADE B)
2. To make a diagnosis of ADHD, the PCP should determine that the Diagnostic
& Statistical Manual of Mental Disorders (4th ed) have been met (GRADE B)
a. Information should be obtained from reports from parents/guardians,
teachers, and other school/mental health clinicians
b. PCP should rule out alternative cause
3. In the evaluation, PCP should include assessment for other conditions that
may co-exist including (GRADE B):
a. Emotional/behavioral- anxiety, depression, ODD, CD
b. Developmental disorders- learning & language disorders,
neurodevelopmental disorders
c. Physical conditions- eg tics, sleep apnea
4. The PCP should recognize ADHD as a chronic condition. Should follow
principles of chronic care model & medical home (GRADE B).
5. Recommendations for treatment depend on patient’s age:
a. Preschool aged children (4-5): prescribe evidence based parent
and/or teacher administered behavior therapy as first line treatment
(GRADE A) & may prescribe methylphenidate if behavioral
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interventions do not provide significant improvement & must have
moderate to sever disturbance in child’s function (GRADE B)
i. In this age group only validated scales are: Conners &
ADHD rating scale IV (ADHD rating scale does not screen
for coexisting conditions)- see below
b. Elementary school age children (6-11): should prescribe approved
medications for ADHD (GRADE A) and/or evidence based parent
and/or teacher administered behavioral therapy- preferably both
(GRADE B).
i. Strong evidence for stimulant medications
ii. Sufficient evidence for atomoxetine, extended release
guanfacine, and extended release clonidine (in that order)
c. Adolescents (12-18): prescribe approved medications for ADHD with
the assent of the adolescent (GRADE A) & may prescribe behavioral
therapy as treatment (GRADE C)- preferably both
i. Recommend getting information from 2 teachers as well as
coaches, school guidance counselors, or leaders of community
activities in which the adolescent participates
ii. It is important to establish the younger manifestations of the
condition that were missed
iii. Strongly consider substance use, depression, and anxiety as
alternative or co-occurring diagnoses.
6. The PCP should titrate doses of medication for ADHD to achieve maximum
benefit with minimum adverse effects (GRADE B)
Samples of Conners EC:
http://www.mhs.com/product.aspx?gr=cli&prod=connersec&id=resources
Sample for ADHD Rating Scale IV: also how to score
http://www.psychtoolkit.com/adhd-rating-scale-iv-adhd-rs.html
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Core symptoms of ADHD for DSM-V:
Inattention
Careless mistakes
Difficulty sustaining attention
Seems not to listen
Fails to finish tasks
Difficulty organizing
Avoids tasks that require
sustained attention
Loses things
Easily distracted
Forgetful
ADHD Inattentive: 6 of 9
Hyperactive-impulsive
Dimension
Hyperactivity
Fidgety
Unable to stay seated
Moves excessively
Difficult engaging in leisure
activities quietely
"on the go"
Impulsive
Blurts answers before q's completed
Difficulty awaiting turn
Interrupts/intrudes on others
Talks excessively
ADHD Hyperactive-impulsive: 6
of 9
ADHD Combined: 6 0f 9 in both
Table 2. Adapted from Peds In Review 2010 31:56. Attention-Deficit/Hyperactivity Disorder-specific Rating
Scales
Evidence Based Behavioral therapies discussed in guidelines:
1. Behavioral parent training
2. Behavioral classroom management
3. Behavioral peer interventions
Side Effect profile of medications discussed in guidelines:
Stimulant common side effects:
 Appetite loss
 Abdominal pain
 Headaches
 Sleep disturbances
 Decreasing growth velocity- effects diminished by 3rd year of treatment (12cm)
Stimulant uncommon side effects:
 Hallucinations
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
Sudden cardiac death (RARE)- screen for WPW, long QT, sudden cardiac
death in family, hypertrophic cardiomyopathy (This is discussed in further
detail next week- ADHD Part 2)
Atomoxetine side effects:
 Somnolence
 GI symptoms
 Decreased appetite
 Increase suicidal thoughts (less common)
 Hepatitis (rare)
ER Guafacine & ER Clonidine side effects:
 Somnolence
 Dry mouth
Contraindications to Medications Used for Treatment of
Attention-Deficit/Hyperactive Disorder
Active Ingredient
Mixed salts of
amphetamine
Contraindication
Monoamine oxidase (MAO) inhibitors within 14 days, glaucoma, symptomatic
cardiovascular disease, hyperthyroidism, moderate-to-severe hypertension
Dextroamphetamine
MAO inhibitors within 14 days, glaucoma, symptomatic cardiovascular disease,
hyperthyroidism, moderate-to-severe hypertension
Methylphenidate
MAO inhibitors within 14 days, glaucoma, symptomatic cardiovascular disease,
hyperthyroidism, moderate-to-severe hypertension, pre-existing severe gastrointestinal
narrowing; use caution when prescribing concomitantly with anticoagulants,
anticonvulsants, phenylbutazone, and tricyclic antidepressants
Atomoxetine
MAO inhibitors within 14 days, glaucoma; may interfere with selective serotonin
reuptake inhibitor metabolism (uses CYP2D6 system); drug interaction with albuterol;
jaundice or laboratory evidence of liver injury
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References:
1. Floet, AM, Scheiner C, Grossman L. Attention-Deficit/Hyperactivity Disorder.
Pediatrics in Review 2010; 31: 56-69.
2. Perrin JM, Friedman RA, Knilans TK et al. AAP policy Statement:
Cardiovascular Monitoring and Stimulant Drugs for AttentionDeficit/Hyperactivity Disorder. Pediatrics 2008; 122 (2): 451-453.
3. Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering
committee on quality improvement & management. ADHD: Clinical Practice
Guideline for the Diagnosis, Evaluation, and Treatment of AttentionDeficit/Hyperactivity Disorder in Children & Adolescents. Pediatrics 2011;
122 (2): 1007-1022
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