Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents - PowerPoint PPT Presentation

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Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

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Title: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents


1
TM
Prepared for your next patient.
Clinical Practice Guideline for the Diagnosis,
Evaluation, and Treatment of Attention-Deficit/Hyp
eractivity Disorder in Children and Adolescents
Mark L. Wolraich, MD, FAAP CMRI/Shaun Walters
Professor of Pediatrics University of Oklahoma
Health Sciences Center
2
Disclaimers
  • Statements and opinions expressed are those of
    the authors and not necessarily those of the
    American Academy of Pediatrics.
  • Mead Johnson sponsors programs such as this to
    give healthcare professionals access to
    scientific and educational information provided
    by experts. The presenter has complete and
    independent control over the planning and content
    of the presentation, and is not receiving any
    compensation from Mead Johnson for this
    presentation. The presenters comments and
    opinions are not necessarily those of Mead
    Johnson. In the event that the presentation
    contains statements about uses of drugs that are
    not within the drugs' approved indications, Mead
    Johnson does not promote the use of any drug for
    indications outside the FDA-approved product
    label.

3
Disclosures
  • Consultant with
  • Lilly
  • Shire
  • Shinogi
  • NextWave

4
Learning Objectives
  • Participants will be able to report on the major
    changes in the revised attention-deficit/hyperacti
    vity disorder (ADHD) guideline.
  • Participants will be able to obtain and use
    appropriate behavior rating scales.
  • Participants will be able to describe the
    importance of considering ADHD as a chronic
    condition.
  • Participants will be aware of the variations in
    treatment recommended for preschool age children
    and adolescents.

5
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6
ADHD Guideline Recommendations
  1. The primary care clinician should initiate an
    evaluation for ADHD for any child 4 through 18
    years of age who presents with academic or
    behavioral problems and symptoms of inattention,
    hyperactivity, or impulsivity. B/strong
    recommendation

7
Prevalence of ADHD in Children
Centers for Disease Control and
Prevention/National Health Care Surveys, 19972006
8
Prevalence and Medication Use
ADHD prev
ADHD not on meds
ADHD diagnosed on meds
ADHD on meds
9
ADHD Guideline Recommendations
  • To make a diagnosis of ADHD, the primary care
    clinician should determine that Diagnostic and
    Statistical Manual of Mental Disorders, Fourth
    Edition (DSM-IV) criteria have been met
    (including documentation of impairment in more
    than 1 major setting) with information obtained
    primarily from parents/guardians, teachers, and
    other school and mental health clinicians
    involved in the childs care. The primary care
    clinician should also rule out any alternative
    cause. B/strong recommendation

10
Evaluation
  • Identify core symptoms.
  • Assess impairment.
  • Identify possible underlying or alternative
    causes.
  • Identify co-occurring (co-morbid) conditions.

11
DSM-IV Core Symptoms of Inattention
Manifestations of the following symptoms must
occur often
  • Avoids/dislikes tasks requiring sustained
    mental effort
  • Cant organize
  • Loses important items
  • Easily distractible
  • Forgetful in daily activities
  • Inattention
  • Careless
  • Difficulty sustaining attention in activity
  • Doesnt listen
  • No follow-through

Must have 6 or more symptoms for at least 6
months to a degree that is maladaptive and
inconsistent with developmental level.
American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders. Fourth
edition. Arlington, VA American Psychiatric
Association 2000
12
DSM-IV Core Symptoms of Hyperactivity- Impulsivity
Manifestations of the following symptoms must
occur often
  • Hyperactivity
  • Squirms and fidgets
  • Cant stay seated
  • Runs/climbs excessively
  • Cant play/work quietly
  • On the go/driven by a motor
  • Talks excessively
  • Impulsivity
  • Blurts out answers
  • Cant wait turn
  • Intrudes/interrupts others

Must have 6 or more symptoms for at least 6
months to a degree that is maladaptive and
inconsistent with developmental level.
American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders. Fourth
edition. Arlington, VA American Psychiatric
Association 2000
13
Assess Function
  • Academic performance
  • Peer relations
  • Sibling relations
  • Parent relations
  • Community activities

14
Clinical Global Impression Scale
15
DSM-IV ADHD Diagnostic Criteria
  • List of core symptoms must be present for past 6
    months.
  • Some symptoms need to be present before 7 years
    of age.
  • Some impairment from symptoms must be present in
    2 or more settings (eg, school and home).
  • Significant impairment (social, academic, or
    occupational) must be present.
  • Other mental disorders need to be excluded as the
    cause of the core symptoms.

American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders. Fourth
edition. Arlington, VA American Psychiatric
Association 2000
16
Inattention or Hyperactive/Impulsive Problems
  • Children who do not meet the criteria of ADHD
    still may have some symptoms of inattention
    and/or hyperactivity/impulsivity fitting the
    category in the Diagnostic and Statistical Manual
    for Primary Care (DSM-PC) of inattention and/or
    hyperactivity/impulsivity. Use of the chronic
    illness model and behavioral interventions are
    appropriate, but medications are not.

American Academy of Pediatrics. In Wolraich ML,
Felice ME, Drotar D. The Classification of Child
and Adolescent Mental Diagnosis in Primary Care.
Elk Grove Village, IL American Academy of
Pediatrics 1996
17
Preschool Age Diagnostic Issues
  • The same criteria are pertinent for preschool age
    children, but it is more difficult to find
    qualified observers of these children.
  • Enroll the child in a program and/or have the
    parents participate in a parent training program.

Greenhill L, Kollins S, Abikoff H, et al.
Efficacy and safety of immediate-release
methylphenidate treatment for preschoolers with
ADHD. J Am Acad Child Adolesc Psychiatry.
200645(11)12841293
18
Adolescent Diagnostic Issues
  • It is much more difficult to get adequate
    observers, as both parents and teachers have less
    opportunity to observe.
  • The risk of substance abuse is higher and must be
    ruled out before a diagnosis can be made.
  • The occurrence of co-morbid conditions,
    particularly anxiety or depression, is more
    frequent.

Wolraich ML, Wibbelsman CJ, Brown TE, et al.
Attention-deficit/hyperactivity disorder in
adolescents a review of the diagnosis, treatment
and clinical implications. Pediatrics.
200511517341746
19
Diagnostic Process
  • Use of ADHD specific rating scales is a clinical
    option in the evaluation of ADHD.
  • Use of broad-band rating scales is not
    recommended in diagnosing ADHD although they may
    be useful for evaluating for coexisting
    conditions.

20
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21
Websites for the Vanderbilt Scales
  • The University of Oklahoma College of Medicine
    http//www.idi.ouhsc.edu/body.cfm?id4779
  • American Academy of Pediatrics - Pediatric Care
    Online https//www.pediatriccareonline.org/pco/ub/
    index/Forms-Tools/Keywords/N/NICHQ

22
ADHD Guideline Recommendations
  1. Evaluation of a child for ADHD should include
    assessment for coexisting conditions, including
    emotional, developmental, and physical. B/strong
    recommendation

23
Co-morbidity Conditions Commonly Co-occurring
with ADHD
  • Disruptive behavior disorders
  • Oppositional defiant disorder
  • Conduct disorder
  • Depressive disorders
  • Anxiety disorders
  • Cognitive disorders
  • Learning disabilities
  • Language disorders
  • Motor disorders
  • Developmental coordination disorder
  • Tic disorders (Tourette's)

24
ADHD Guideline Recommendations
  • The primary care clinician should establish a
    treatment program that recognizes ADHD as a
    chronic condition and a child with ADHD as a
    child/adolescent with special health care needs
    who needs a medical home. B/strong recommendation

25
Methylphenidate therapy bout length by patient age
Miller AR, Lalonde CE, McGrail KM. Childrens
persistence with methylphenidate therapy a
population-based study. Can J Psychiatry.
200449(11)761768
26
Treating ADHD as a Chronic Condition
  • Educate parents and patients about ADHD.
  • Develop a partnership with the family.
  • Develop a management plan with specific targeted
    goals.
  • Include the teachers if at all possible.
  • Requires ongoing monitoring and anticipation of
    developmental changes.

27
ADHD Guideline Recommendations
  1. Recommendations for treatment of children and
    youth with ADHD vary depending on the patients
    age

28
Preschool-aged Children (45 Years of Age)
  1. Prescribe evidence-based parent- and/or
    teacher-administered behavior therapy as the
    first line of treatment. A/strong recommendation

and May prescribe methylphenidate if the behavior
interventions do not provide significant
improvement and there is moderate-to-severe
continuing disturbance in the childs function.
B/recommendation
29
Preschool Age Treatment Issues
  • While stimulant medications are appropriate for
    preschool age children based on recent research,
    given that a third of the children in a
    multi-site study improved on behavioral
    interventions alone, it is more appropriate to
    initiate a parent training program first before
    utilizing medication and only treat the more
    severe cases.
  • Preschool age children frequently have a slower
    metabolism of the medications and can start at a
    lower dose and titrated at a slower rate.

Greenhill L, Kollins S, Abikoff H, et al.
Efficacy and safety of immediate-release
methylphenidate treatment for preschoolers with
ADHD. J Am Acad Child Adolesc Psychiatry.
200645(11)12841293
30
Elementary School-aged Children (611 Years of
Age)
  1. Prescribe FDA-approved medications for ADHD.
    A/strong recommendation

and/or Evidence-based parent- and/or
teacher-administered behavior therapy as
treatment for ADHD. Preferably both.
B/recommendation
31
Adolescents (1218 Years of Age)
  1. Prescribe FDA-approved medications for ADHD with
    the assent of the adolescent. A/strong
    recommendation

and May prescribe behavior therapy as treatment
for ADHD. C/recommendation Preferably both.
32
Non-Stimulants
  • Atomoxetine is a highly specific norepinephrine
    reuptake inhibitor.
  • Extended release guanfacine and clonidine are
    alpha 2 adrenergic agents.

33
ADHD Guideline Recommendations
  1. The primary care clinician should titrate doses
    of medication for ADHD to achieve maximum benefit
    with minimum adverse effects. B/strong
    recommendation

34
Summary
  • Children from preschool age through adolescent
    age can be diagnosed and treated for ADHD.
  • Both medications (stimulants, selective
    norepinephrine reuptake inhibitors and alpha
    adreneric agents) and behavior therapy are
    effective and safe treatments for ADHD.
  • Effective treatments require appropriate
    titration and ongoing monitoring to remain
    effective.

35
Caring for Children With ADHD A Resource Toolkit
for Clinicians, 2nd Edition
This comprehensive ADHD resource provides a full
set of tools for assessment and diagnosis,
treatment and medication, monitoring and
follow-up, parent education and support, and
coding and payment. Included are more than 40
practice-tested toolsmany in English and
Spanishon one convenient CD-ROM. The ADHD
toolkit components have been evaluated and
refined based on input from the American Academy
of Pediatrics Quality Improvement Innovation
Network (QuIIN). For more information or to
order visit the AAP bookstore at
http//tinyurl.aap.org/pub169531.
36
Additional ADHD Resources on Pediatric Care
Online (www.pediatriccareonline.org)
  • Forms Tools https//www.pediatriccareonline.org/
    pco/ub/index/Forms-Tools/Keywords/A/ADHD
  • Patient Handouts https//www.pediatriccareonline.o
    rg/pco/ub/index/Patient_Handouts_AAP/Keywords/A/AD
    HD
  • AAP Textbook of Pediatric Care https//www.pediatr
    iccareonline.org/pco/ub/index/AAP-Textbook-of-Pedi
    atric-Care/Topics/A
  • Point-of-Care Quick Reference https//www.pediatri
    ccareonline.org/pco/ub/index/Point-of-Care-Quick-R
    eference/Topics/A

37
For more information
  • On this topic and a host of other topics, visit

    www.pediatriccareonli
    ne.org Pediatric Care Online is a convenient
    electronic resource for immediate expert help
    with virtually every pediatric clinical
    information need. Must-have resources are
    included in a comprehensive reference library and
    time-saving clinical tools.
  • Haven't activated your Pediatric Care Online
    trial subscription yet? It's quick and easy
    simply follow the steps on the back of the
    card you received from your Mead Johnson
    representative.
  • Haven't received your free trial card? Contact
    your Mead Johnson representative or call
    888/363-2362 today.
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