Download steinfeld_adhd - Washington Academy of Physician Assistants

PRIMARY CARE MANAGEMENT OF
ADHD
Bradley Steinfeld, PhD
Assistant Director of Professional Services
Group Health Behavioral Health Services
OBJECTIVES
• Overview of prevalence and characteristics of childhood and adult
ADHD
• Role of Primary Care Provider in assessment and treatment of
ADHD
• Tools to assist Primary Care Provider in diagnosis and treatment of
ADHD
Primary Reference Resources
• Group Health Cooperative Adult and Childhood Clinical Guidelines,
2011
• American Academy of Pediatrics 2011 Guidelines on Childhood
ADHD
• ACAP ADHD Took Kit 2011
• NICE Adult and Childhood ADHD Guidelines, 2008.
Role of Specialties
• Family practice providers who have an interest and adequate
training can diagnose and treat children with ADHD
• Pediatric providers should have the skills to diagnose and treat
children with ADHD
• Behavioral Health Services (BHS) disciplines –should have the skills
to diagnose and treat the children with ADHD who are referred to
them
• Consider the involvement of mental health professionals for
diagnosis and treatment of ADHD for children under the age of 5
years
PREVALANCE OF ADHD
A report from the Center of Disease Control and Prevention
(2010) provides the following information about prevalence:
•
In 2007, the estimated prevalence of parent-reported
ADHD among children aged 4-17 years was 9.5%
•
ADHD was more than twice as common among boys
as girls (13.2% vs 5.6%)
•
30-40% of children with ADHD continue to have
ADHD as adults
Prevalence of Co morbidities:
•
•
•
•
•
Learning disabilities
Social skills deficits:
Oppositional defiant disorder:
Anxiety:
Depression:
25%
50%
60%
20%
30%
DSM-IV ADHD Criteria
Presence of either of the following (1 and/or 2)
1.
Six (or more) of the following symptoms on inattention have
persisted for at least 6 months to a degree that is maladaptive and
inconsistent with developmental level:
•
•
•
Often fails to give close attention to details or make careless
mistakes in schoolwork, work or other activities
Often has difficulty sustaining attention in tasks or play
activities
Often does not seem to listen when spoken to directly
DSM-IV (continued)
• Often does not follow through on instructions and fails to finish
schoolwork, chores or duties in the workplace (not due to
oppositional behavior or failure to understand instructions)
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)
• Often loses things necessary for tasks or activities (e.g. toys, school
assignments, pencils, books or tools)
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities
Additional DSM-IV Criteria
2. Hyperactivity/Impulsivity (six or more of the following)
•
•
•
•
•
•
Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or in other situations in which remained
seated is expected
Often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjected
feelings of restlessness)
Often has difficulty playing or engaging in leisure activities quietly
Is often “on the go” or often acts as if “driven by a motor”
Often talks excessively
Additional DSM-IV Criteria (continued)
Impulsitivity
• Often blurts out answers before questions have been completed
• Often has difficulty waiting turn
• Often interrupts or intrudes on others (e.g. butts into converstaions
or games)
DSM-IV Classification of ADHD
Classifications:
Combined type ADHD
• If criteria for both inattention and hyperactivity-impulsivity are met for
the past 6 months
Predominantly inattentive type ADHD
• If criteria for inattention but not hyperactivity-impulsivity are met for
the past 6 months
Predominantly hyperactive-impulse type ADHD
• If criteria for hyperactivity-impulsivity but not inattention are met for
the past 6 months
Keys to Assessment
• Presence of ADHD related symptoms as reported by parents and
teacher (e.g. inattention, hyperactivity, impulsivity) in multiple
settings
• Symptoms significantly impact the child’s life
• Symptoms were present prior to age 7 years
Proposed DSM-5 Criteria Changes
• The three subtypes of childhood ADHD will no longer be
identified as separate conditions
• The age of onset will be extended up to age 12
• Reduction of symptom threshold for diagnosis from six to four
symptoms
Assessment of suspected ADHD in children/adolescents
Assessment
Action/Tool
Assess for ADHD
Use the Vanderbilt scales
(Rating scales alone should not be used to make a
diagnosis)
Vanderbilt parent rating scale
Vanderbilt teacher rating scale
Interview patient and parent (s)
Confirm that symptoms:
 Are causing impairment in at least two settings (e.g. home and school)
 Begin by age 7 years
Screen for psychiatric co morbidities
Additional screening for co morbidities
Assessment
Action/tool
Depression
PHQ-9 normed for children age 12 or greater
Anxiety
GAD-7 no adolescent norms
Drug/Alcohol Use:
CRAFFT
Learning Disabilities
•
If a child is struggling in school, it may be due to ADHD, LD or both
•
If a child is having moderate difficulty (passing classes, able to read but not
completing assignments) consider ADHD treatment before assessment of
LD
•
If a child is having significant difficulty (failing classes, not being able to
read) consider assessment of LD through the school.
Psychological testing
 There is no psychological test that can diagnose ADHD
 Some ADHD children have executive functioning deficits (i.e. planning,
organization, working memory)
 Can typically be detected through clinical interview
 Psychological testing can help determine extent and severity of executive
functioning deficits
 Testing can help determine extent of co morbid disorders if not clarified in clinical
interview or rating scales.
Not recommended (diagnostic testing)
• Brain imaging (e.g. SPEC, PET scan, MRI, or CT) is
NOT recommended for diagnosing childhood ADHD
Treatment
The primary treatment goal is to reduce (control, manage) ADHD symptoms and achieve
a clinically appropriate level of stability and baseline functioning.
Establish the specific treatment goals with the parents and child
These goals will typically target specific behaviors at home and school
A multi-modal approach to treatment of ADHD by combining medication, behavioral
modalities, parent education and school based interventions is recommended
Shared decision making for medication and behavioral treatments is recommended
Parent education and school based educational interventions are also recommended
Parent Support
www.chadd.org
• Detailed information about the causes, symptoms and treatment of
ADHD. Includes an online magazine, information about support
groups in the Puget Sound area, and books for purchase.
Pharmacologic Options
General approach
•
•
•
•
•
Recommend shared decision making for pharmacologic treatment based on
impairment type and parent/patient interviews
Parents and patients should be informed of the benefits and harms of pharmacologic
treatment
The primary intervention for children under 5 years of age is behavioral therapy.
ADHD medications are not generally recommended; consider consultation with or
management by a child psychiatrist
Prescribe no more than 3 months of medication at any one time
Provide medication coverage during school and homework hours. Most experts also
advise weekend dosing, as social and family function is as important as academic
function.
Pharmacologic Options – continued
Medication Selection
• Stimulant medication is the recommended first line treatment
• What about increased cardiac risk with stimulants. Recent NEJM article found no
increased risk
• Initiate medications at the lowest possible dose and titrate slowly. Before switching
medications, titrate to the maximum dose if there are no side effects.
• If one stimulant is not working or produces too many adverse effects, try another
stimulant before using a different class of medications. Response to one stimulant
does not predict response to others.
• Combining medications from two or more different drug classes is not recommended
to treat the core symptoms of ADHD, though this practice may be used to treat other
symptoms.
• Assess adolescents for substance abuse or diversions, initially before prescribing any
medication and again before authorizing refills. If they are abusing or suspected of
abusing drugs, prescribe a non-stimulant medication as a first-line treatment
Recommended pharmacologic options for children/adolescents aged 5 and older
with ADHD
Medications
Methylphenidate (generic
Concerta)
Duration of
behavioral
effects
10-12 hours
Initial
dose
18 mg daily
Methylphenidate ER
(generic Methylin ER)
6 – 8 hours
10 mg daily
Dextroamphetamine SR
8 hours
5 mg daily
Amphetamine/Destroamphetamine
mixed salts (Adderall XR)
8 – 12 hours
5 mg daily
Titration
schedule
Maximum
daily dose
Ages 6-12:
54mg
Increase by 18
Ages 13-18: 72
mg daily at
weekly intervals mg
Increase by 10
mg daily at
weekly intervals 60 mg
Increase by 5
mg daily at
weekly intervals 40 mg
Increase by 5
mg daily at
weekly intervals 30 mg
Immediate-release ADHD medications 2,4
Methylphenidate
Dextroamphetamine
Amphetamine/Dextroamph
etamine mixed salts
3 -4 hours
4-5 hours
4-6 hours
2.5-5mg 1-2
times daily
Increase by
2.5-5mg daily
at weekly
intervals, split
dose 3 times
daily
60 mg
2.5-5mg 1-2
times daily
Increase by
2.5 – 5 mg
daily at
weekly
intervals, split
does twice
daily
40 mg
2.5-5mg 1-2
times daily
Increase by
2.5-5mg daily
at weekly
intervals, split
does twice
daily
40 mg
(second –line medication first-line medication
for special circumstances, such as substance abuse or diversion)
Non-stimulant ADHD medication
Medications
Duration of
behavioral
effects
Atomoxetine
8-24 hours
PA (Strattera)5
Initial Dose
Titration
schedule
Weight ≤ 70 kg: 0.5 mg/kg/day x 3 then 1.2
mg/kg/day
Weight ≥ 70 kg: 40 mg daily x 3 days, then
80 mg daily
Maximum
daily dose
1.4 mg/kg daily
or 100mg
whichever is
less7
All patients: single dose after dinner or
split dose twice daily with food
Guanfacine IR 16-24 hours
0.5 mg daily given
at bedtime for a
few nights, then
twice daily
Increase by 0.5
mg daily at weekly
intervals (in 1 to 2
doses)
4 mg daily
All ADHD patients on medication
Physical Changes
• Weight
• Height
• Blood Pressure
• Pulse
Medication tolerance and side effects
If patient develops any cardiac adverse effects on stimulants, stop the medication
immediately and consider referral to Cardiology.
Children receiving doses that are too high or who are overly-sensitive to
medications may become overly focused or appear dull.
Assess for medication rebound, especially for patient on short acting agents
All ADHD patients on medication
After initiation of medication
• Schedule follow-up office visit within 30 days
• Schedule additional visits every 1-2 months until medication effective doses
is established
• Use Vanderbilt Rating Scale to track changes at home and school
Once a patient is stable on a medication and dose
• Telephone or secure email assessment every 3 months and when refills are
requested
• Office visit every 6 months
If medication or dosing is changed
• Contact weekly via telephone or secure message until stable
Additional Medical Tips
•
For children who do not respond to stimulants or strattera, consider
consultation with Children’s/U of W child psychiatry Partnership Access Line
(PAL) a telephone based child psychiatric consultation service. It is
specifically designed for consultation for primary care providers in
Washington State. While established for Medicaid population, consultation
is available for any child under age 21.
Website: http://palforkids.org/
Phone number:
866-599-7257 8:00am-5:00pm M-F
Behavioral Modalities
• Combined pharmacological and behavioral therapy is no more
effective than medication alone in reducing the primary symptoms of
ADHD: inattentiveness, hyperactive and impulsivity.
• However, ADHD often has a secondary impact on social and
especially school functioning.
• Therefore, behavioral interventions may be appropriate if:
1. The family declines pharmacological treatment
2. Medication produces only partial remission of symptoms
3. There are co-morbid conditions that may not respond to stimulant
medication treatment.
Parental Management Strategies
• Maintain a daily schedule with routine activities at the same time of
day
• Limit sensory distractions (e.g. loud music, video games, computer
and television)
• Create an organization plan for your house and have specific spots
for leaving school work, toys, clothes, etc.
• Set small, attainable goals. Develop and use a visual system when
possible
• Help your child stay on task with simple instructions and friendly
reminders; congratulate them when they follow through
Parental Management Strategies - continued
• Limit choices. Your child will like options but limit them
to two or three so your child does not feel overwhelmed
or frustrated
• Find activities that can help promote social skills
• Find something that your child is good and help promote
it (e.g. drawing, puzzles, Lego's, raising pets)
Parental Management Strategies - continued
• Reward positive behavior. Kind words, praise, hugs and small
rewards both help promote appropriate behavior and help children
feel good about themselves.
• Use calm discipline. Redirect children to another activity when they
are being disruptive. Make sure your child is calm before talking to
them about inappropriate behavior.
• Most importantly, enjoy your child by spending time with them,
playing with them and doing fun activities.
Strategies for Managing ADHD in School
School is often the most difficult environment for a child with ADHD, as
the ability to stay on task, be focused and avoid distraction is critical
to being successful in school.
• The first step in ensuring success at school is finding the right
teacher.
• Teachers who are nurturing and firm are often best type of teachers
to work with ADHD children.
• Maintain close contact with the teacher
• Have a good homework area away from distractions.
• Set up a regular “study hour” free of electronics, when the parent (s)
are available for tutoring, support and encouragement
Laws that can help if the ADHD child is having trouble in
school
Section 504 of the Rehabilitation Act protects the rights of people with disabilities
•
Available to ADHD child as first step if not successful. Focuses on accommodations,
not special ed. Typically needs diagnosis from physician. Accommodations can
include:
–
–
–
–
–
–
–
–
–
Extended time for testing and homework difficulties
Allow use of calculator and/or laptop
Tailoring and/or minimizing amount of homework assignments
Limiting repetitive homework
Preferential seating
Organizational assistance
Sometimes assigning note-taking or study buddy
Changing the delivery of tests
Use of behavioral management techniques
Laws that can help if the ADHD child is having trouble in
school – continued
Individual with Disabilities Education Act of 1997 (IDEA)
• If implementing a 504 plan has not been successful IDEA services
or special education may be appropriate.
• Parent or teachers can request evaluation for special education
services if they feel the child may benefit from such services.
• There are specific steps dictated by state and federal law regarding
what exactly occurs in terms of timeline and type of evaluation.
• In most circumstances, an evaluation must be completed within 30
days of the request and include observation of child and assessment
of his or her academic and cognitive skills.
Laws that can help if the ADHD child is having
trouble in school – continued
• ADHD is considered to be a health impairment which is one of the
qualifying conditions for special education.
• Your child's physician may be asked to provide documentation of
this diagnosis.
• If the child qualifies for special education, an individualized
educational plan (IEP) is developed by school that addresses
deficits identified in the evaluation.
• This educational plan includes measurable objectives that are
reviewed by the school and the parents annually.
• Parents as well as the student (particularly if they are an adolescent)
have opportunity to provide input into the plan.
Adult ADHD Characteristics
BEHAVIOR MANIFESTATIONS
1.
Trouble focusing and concentrating
2.
Easily distracted and sidetracked
3.
Trouble finishing tasks
4.
Themes of intense frustration and underachievement
5.
Poor organizational and planning skills
6.
Procrastination
7.
Mental and physical restlessness
8.
Impulsive decision making
9.
Poor academic grades for ability
10. Chronic lateness
11. Frequently loses things
Adult ADHD Characteristics
Associated Features
1.
Poor self-esteem
2.
Academic underachievement
3.
Peer relationship problems
4.
Demoralization
5.
Mood liability
6.
Low frustration tolerance
7.
Temper outbursts
8.
Work problems
9.
Increased auto accidents
10. More speeding tickets
ADHD in Adults
Prevalence:
a.
30-40% of children with ADHD continue to have ADHD as adults,
so incidence of ADHD in adults is lower (1-3% population)
b.
c.
Women represent a high proportion of the adult ADHD.
Co morbid conditions tend to be more prevalent in adults with a higher
frequency of depression and anxiety disorders. Prevalence of these
disorders are as follows:
1. Oppositional Defiant Disorder
2. Learning Disabilities
3. Antisocial Personality Disorder
4.
5.
6.
7.
Major Depressive Disorder
Bipolar Disorder
Anxiety Disorder
Alcohol and/or Drug Dependence
30%
25-30%
18% in males
8% in females
30-40%
15%
40-50%
20-30%
Diagnosis of Adult ADHD
GENERAL APPROACH
•
Diagnosis is typically made by a mental health provider. Primary care
providers can make a diagnosis if they have expertise or training in adult
ADHD. In addition:
– Masters level therapists can assess for adult ADHD.
– Psychologists can provide additional consultation if the clinical interview
and rating scale data are not sufficient to clarify diagnosis
– Psychiatrists can provide consultation if there are additional questions
regarding diagnosis/role of co morbid conditions, particularly if there are
questions regarding psychopharmacological management.
Diagnosis is based on comprehensive clinical and psychosocial
assessment, impact of symptoms on functioning, developmental history
and review of rating scales.
Diagnosis - continued
• Rating scales alone are not sufficient to make a diagnosis of adult
ADHD.
• Diagnosis requires determining that symptoms:
– Began in childhood and have persisted through life, and
– Are not explained by other diagnoses, and
– Have resulted in, or are associated with moderate or severe
psychological, social, and/or educational or occupational
impairment
Screening for Adult ADHD
Eligible population
Assessment
Adult patients who have
symptoms consistent
with ADHD
Screen with the 6 item Adult ADHD Self-Report rating scale
Ask additional follow-up questions:
What difficulty are these symptoms causing in your life?
How old were you when these symptoms first occurred?
Screen for depression
Use the first two questions of the PHQ-9. If the patient answers
2 or higher to either, use the full PHQ-9.
Screen for alcohol and/or drug misuse or diversion.
Use the Audit and DAST screen tools.
Cardiac Status: No evidence of relationship of stimulants to
cardiac events, consider screening for cardiac event history
Adult Self-Report ADHD Rating Scale (available in public domain)
This Adult Self-Report Scale-V1.1 (ASRS-V1.1) Screener is intended for people aged 18 years or older.
Sometimes
Date:
Rarely
Patient Name:
Very
Often
Often
Never
Check the box that best describes how you have felt and conducted yourself
over the past 6 months. Please give the completed questionnaire to your
healthcare professionals during your next appointment to discuss the results.
1. How often do you have trouble wrapping up the final details of a
project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you
have to do a task that requires organization?
3. How often do you have problems remembering appointments or
obligations?
4. When you have a task that requires a lot of thought, how often do you
avoid or delay getting started?
5. How often do you fidge; or squirm with your hands or feet when you
have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like
you were driven by a motor?
The 6 question Adult Self-Report Scale-Version1.1 (ASRS-V1.1) Screener is a subset of the WHO’S 18 question Adult ADHD Self-Report
Scale. Version 1.1 (Adult ASRS-V1.1)Symptom Checklist.
AT28491 PRINTED IN USA. 30C0054636 0903500 ASRSV1.1 Screener COPYRIGHT©2000 World Health Organization (WHO). Reprinted
with permission of WHO. All rights reserved.
Screening Recommendations and Initial Primary Care
Workup
Recommendations for screening for ADHD
Eligible population
Test
Adult patients suspected of 6-item Adult ADHD
having
Self-Report Scale
ADHD
(ASRS-V1.1)
Primary care
screening
recommended for
adult ADHD
Score
0-3 marks the
darkly shaded
boxes
Interpretation
Unlikely to have
ADHD, no need for
additional
evaluation
4 or more
marks in the
darkly shaded
boxed
Symptoms suggest
possibility of
ADHD and need
for additional
evaluation
Diagnosis of ADHD
Diagnostic approach
Action
Assess Clinical and psychosocial status
Assess current mental status and review behavioral and
symptomatic concerns in the different settings of the
person’s life.
Establish history of ADHD symptoms in childhood
(preferably before the age of 7) either retrospectively
or prospectively. Preferred: Use behavioral symptoms
noted in school records or information from parents or
sibling. Acceptable: Use patient self-report when
collateral information is not available.
Confirm symptoms have clinically significant impact on
social, educational or occupational functing.
AND
Confirm impairment exists in a least two different,
important settings (e.g. home and work).
Establish developmental history of ADHD
Assess impact of symptoms on functioning
Diagnosis of ADHD
Diagnostic approach
Action
Use rating scale
Use the 18-item Adult Self-Report Scale
(PDF)(ASRS-V1.1); condier likelihood of
ADHD if score on part A is 4 or more. The
frequency scores in part B provide additional
cues and can serve a further jporbes into the
patient’s symptoms
Use interview or rating scale to corroborate
presence of ADHD symptoms. Consider
using the full version of the ASRA and
modifying the language for observer usage.
Collect observer reports (e.g. partner,
parent, friend)
Psychiatric Co morbidities
• Psychiatric Co Morbidities (i.e. depression, anxiety, substance use)
are the norm rather than the exception. Consider use of Phq-9,
Gad-7, Audit, Dast.
• As with children, no psychological test to diagnose ADHD
• Psychological testing can be helpful for assessment of learning
disabilities and in particular executive functioning deficits.
Not recommended (diagnostic testing)
• Brain imaging (e.g. SPEC, PET scan, MRI, or CT) is NOT
recommended for diagnosing Adult ADHD
Education Adult ADHD patients
• It’s a chronic disease that waxes and wanes
• Very likely you have other problems (i.e. depression/anxiety) in
addition to ADHD
• It’s a real disorder, YOU ARE NOT LAZY, STUPID OR CRAZY
• It’s something you can change and improve
• Though, there is not a cure for ADHD
• Treatment including medication AND lifestyle changes
Lifestyle Changes
• Establish structure and use devices (smart phone/lists) to help with
reminders
• Pick vocations and hobbies that are of most interest
• Establish a social supportive network (“it’s ok to have friends/family
help with reminding”)
• Meet others with adult ADHD (“I am not alone”)
• Eat well, sleep well and exercise
• Substance use make ADHD symptoms worse. Develop a drug free
peer support network and/or seek treatment if necessary
Treatment: Pharmacological Options
Drug treatment should be the first-line approach for adults with ADHD
with either moderate or severe levels of impairment, unless the patient
would prefer a psychological approach (NICE 2008).
Before initiation of stimulant treatment for adults with ADHD:
•
•
•
•
Inform patients that no clinical trials exist on long-term stimulant therapy
for adults with ADHD; the safety of long-term use is not known.
Inform patients of the risk of time-limited dysphoria if stimulant therapy is
discontinued after long-term use.
Inform patients of the other risks of stimulant therapy, including elevation
of blood pressure, cardiac arrhythmia and death, sleep disturbance,
anorexia, mood or behavior disturbance, psychological dependence, and
abuse potential.
Cardiac Assessment: At least history ?
Initiate ADHD medications at the lowest possible dose and titrate slowly.
Before switching medications, titrate to the maximum dose (if there are no side
effects).
Recommended pharmacologic options for adults with ADHD
Medication dosage forms
st
Initial dose
Titration schedule
Maximum recommended
daily dose
1 line
Recommended unless patient has a history of substance misuse or diversion with risk for relapse or a cardiac
or other medical condition for which stimulants would be contraindicted.
Methylphenidate HCL ER
10 mg daily in
Increase by 10 mg every 7
60 mg
or
the morning
days (typically dosed twice
daily) as needed
Methylphenidate HCL ER
18 mg daily in
Increase by 10 mg every 7
40 mg
(generic Concerta)
the morning
days (typically dosed twice
daily) as needed
nd
2 line
Alternative recommendation unless patient has a history of substance misuse or diversion with risk for relapse
or a cardiac or other medical condition for which stimulants would be contraindicted.
Amphetamine mixed salts
10 mg daily in
Incread by 10 mg every 7
60 mg
(Adderall XR)
the morning
days as needed
Or
Recommended pharmacologic options for adults with ADHD - continued
Medication dosage
forms
nd
2 line – continued
Dextroamphetamine SR
Initial Dose
10 mg daily in the
morning
Maximum
recommended daily
Titration schedule
dose
Increase by 10 mg every 40 mg
7 days (typically dosed
twice daily) as needed
3rd line
First line for patients if stimulants are contraindicted (e.g. cardiac condition or history of substance
misuse or diversion)
Atomoxetine (Strattera) 40 mg daily in the
Increase to 80 mg after 100 mg
{PA}
morning
≥ 3 days. May increase
to 100 mg after 2-4
additional weeks as
needed
Recommended pharmacologic options for adults with ADHD
Maximum
recommended daily
dose
Medication dosage
forms
Initial dose 1
Titration schedule
Other alternatives
First-line agent for patients with a history of substance misues of diversion with risk for relapse (unless
the patient is abusing alcohol)
Bupropion IR
100 mg twice daily x 7
After 4 weeks at 100mg 450 mg (IR)
days, then increase
three times daily,
or
three times daily
incrase to 200 mg twice
daily
Bupropion SR
150 mg daily in the
After 4 weeks at 150 mg 400 mg (SR)
morning x 7 days, then
twice daily, increase to
increase to 150 mg
200 mg twice daily
or
twice daily (Consider
starting at lower doses
(e.g. 100mg})
Bupropion XR
150 mg daily in the
After 4 weeks at 150 mg 450 mg (XR)
morning
daily, increase to 300
mg daily
Follow Up/Monitoring
At all follow up visits:
• Assess whether the patient’s behavior or functional goals are met
• Consider using the 6 item ASRS to determine degree of treatment effectiveness
Medication Monitoring
Recommended medication monitoring
Medication
All Medications
Stimulants
Atomoxetine
Bupropion
Items to monitor
Frequency
Medication adherence
1. Initially and while titrating dosage, monitor
Treatment effectiveness
every 3-4 weeks
Adverse impact on sleep or behavior
2. Then, every 3 months until stable
Adverse impact on appetite or weight
3. Once stable, every 6 months
Blood pressure
Heart rate
Evidence of abuse or diversion
potential
Blood pressure
Neuropsychiatric effects(e.g. anxiety,
irritability, hypomania, suicidal
ideation)
Blood pressure
Neuropsychiatric effects (e.g.
anxiety, irritability, hypomania,
suicidal ideation)
Cognitive Behavioral Therapy (CBT)
Optimally, CBT should be combined with pharmacological treatments that
improve the core ADHD symptoms of inattention, impulsivity, hyperactivity,
and/or distractibility.
Consider CBT when:
•
•
•
•
•
It can be used in combination with medications, or especially when
medications alone have proved to be only partially effective or ineffective.
The patient has made an informed choice not to use medications or is
intolerant of them.
The patient has difficulty accepting the diagnosis of ADHD and adhering to
a medication regimen.
The patient has a co morbid condition such as depression or anxiety that
could benefit from CBT.
Symptoms are remitting and psychological treatment is considered
sufficient for targeting residual (mild-to-moderate) functional impairment.
CBT for ADHD
Skills
Details of teaching
Organization and Planning

Problem solving






Promote consistent ues of organizational aids such as calendars,
checklists, electronic devices, whiteboards, sticky notes, etc.
Develop triage system for mail and other pages
Structure the day and the environment
Develop problem-solving skills
Learn to look at a situation rationally
Learn to adaptively think about problems and stressors through positive
self-talk
Learn to identify and disrupt negative thoughts
CBT for ADHD - continued
Skills
Distraction management
Procrastination management
Details of teaching
 Build and maximize one’s attention span. This includes
breaking tasks into smaller steps that correspond with an
individual’s attention span
 Learn to effectively use a timer and other distractibility
reminders
 Develop motivational skills to deal with problems with
procrastination
Not Recommended (Non-Pharmacologic Options)
•
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Elimination of sugar, salicylates, or artificial coloring from diet
Nutritional supplements such as Glyconutritional supplements, fatty acid
supplementation, mega dose vitamins, amino acid supplementation, or
herbals
Sensory integration training
Anti-motion sickness medication
Anti-fungal medication for Candida
Chiropractic treatments
Optometric vision training
Metronome training
Neuro/biofeedback
Web Sites
• A.D.D. Warehouse
www.addwarehouse.com
Books for purchase and other resources.
• Attention Deficit Disorder Resources
www.addresources.org
Books for purchase and other reading material, links to more web
sites, and information about support groups in the Puget Sound
area.
• Children and Adults with Attention Deficit/Hyperactivity Disorder
www.chadd.org
Detailed information about the causes, symptoms and treatment of
ADHD. Includes an online magazine, information about support
groups in the Puget Sound area, and books for purchase.
• Helpguide.org
www.helpguide.org
Resources and references for adult ADD/ADHD self-help.
Evidence/References
•
Canadian Attention Deficit Hyperactivity Disorder Resource
Alliance (CADDRA). Canadian ADHD Practice Guidelines, Third
Edition. 2011. Available online at:
http://www.caddra.ca/cms4/pdfs/caddraGuidelines2011.pdf [PDF]
•
Kooij S, Bejerot S, Blackwell A, et al. European consensus
statement on diagnosis and treatment of adult ADHD: The European
Network. BMC Psychiatry. 2010;10:67. Available online at:
http://www.biomedcentral.com/content/pdf/1471-244x-10-67.pdf [PDF]
Evidence/References - continued
Additional information was pulled from these sources:
• National Institute for Health and Clinical Excellence (NICE).
Attention deficit hyperactivity disorder: Diagnosis and management
of ADHD in children, young people and adults. NICE Clinical
Guideline 72. 2008. Available online at:
http://www.nice.org.uk/CG72
• Nutt DJ, Fone K, Asherson P, et al. Evidence-based guidelines for
management of attention-deficit/hyperactivity disorder in
adolescents in transition to adult services and in adults. J
Psychopharmacol. 2007;21(1):10–41. Available online at:
http://www.bap.org.uk/pdfs/ADHD_Guidelines.pdf [PDF]
References
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Centers for Disease Control and Prevention (CDC). Increasing prevalence of parent-reported
attention-deficit/hyperactivity disorder among children-United States, 2003 and 2007. MMWR.
2010;59(44):1439–1443.
•
Cooper et al., ADHD drugs and serious cardiovascular events in children and young adults, New
England Journal of Medicine. 2011, 10, 1056-1066.
•
Faraone SV. Using meta-analysis to compare the efficacy of medications for attentiondeficit/hyperactivity disorder in youths. PT. 2009;34(12):678–694
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Faraone SV, Buitelaar J. Comparing the efficacy of stimulants for ADHD in children and
adolescents using meta-analysis. Eur Child Adolesc Psychiatry. 2010;19(4):353–364.
•
Institute for Clinical Systems Improvement (ICSI). ADHD, attention deficit hyperactivity disorder in
primary care for school-age children and adolescents, diagnosis and management (guideline). 8th
edition, March 2010.
•
Kaiser Permanente. Child/adolescent attention deficit/hyperactivity disorder (ADHD) clinical
practice guideline. December 2009.
References - continued
•
Keen D, Hadjikoumi I. ADHD in children and adolescents (updated). Clin Evid. 2011;02:312.
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Molina BS, Hinshaw SP, Swanson JM, et al. The MTA at 8 years: prospective follow-up of
children treated for combined-type ADHD in a multisite study. J Am Child Adolesc Psychiatry.
2009;48(5):484–500.
•
The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for
attention deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56(12):1073–1086.
•
National Institute for Health and Clinical Excellence (NICE). Attention deficit hyperactivity disorder.
Diagnosis and management of ADHD in children, young people and adults (guideline). September
2008.
•
Raz R, Gabis L. Essential fatty acids and attention-deficit-hyperactivity disorder: a systematic
review. Dev Med Child Neurol. 2009;51(8):580–592.
•
Van der Oord S, Prins PJ, Oosterlaan J, Emmelkamp PM. Efficacy of methylphenidate,
psychosocial treatments and their combination in school-aged children with ADHD: a metaanalysis. Clin Psychol Rev. 2008;28(5):783–800.
Books
• Mastering Your Adult ADHD, A Cognitive Behavioral Treatment
Program, Client Workbook, by Safren, Sprich, Perlman, and Otto
• Delivered from Distraction by Hallowell and Ratey
• Women with Attention Deficit Disorder: Embrace Your Difference
and Transform Your Life by Solden
Other Web Based Resources
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•
•
•
A.D.D. Warehouse
www.addwarehouse.com
Books for purchase and other resources.
Attention Deficit Disorder Resources
www.addresources.org
Books for purchase and other reading material, links to more web sites, and
information about support groups in the Puget Sound area.
Learning Disabilities Association of America (LDA)
www.ldanatl.org
Information, resources, and support for learning disabilities for
parents/teachers.
Washington PAVE
www.wapave.org
Community-based program for parents of children with disabilities.