ADHD

Introduction:

Attention-Deficit Hyperactivity Disorder (ADHD) is one of the most prevalent psychiatric illnesses occurring in children and adolescents. Although it is often a subject of debate in popular media, there is an enormous body of evidence supporting the validity of the diagnosis and documenting the substantial adverse outcomes associated with this condition. Even though the early identification, assessment, and treatment of ADHD are considered to be well within the scope of practice of primary care, specialists may be needed for patients who are refractory to treatment and/or suffering from co-occurring psychiatric issues. As discussed in the American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry clinical practice guidelines, the diagnosis of ADHD can be reliably made on the basis of an office-based clinical assessment. However, it is necessary to include detailed information from a reliable informant in multiple settings (i.e., a parent and a teacher). Using widely available rating scales, such as the Vanderbilt scale, is an efficient method of gathering this information.

Please remember, however, that as with all childhood psychiatric disorders, many of the individual symptoms are nonspecific. Therefore, in addition to the gathering of ADHD symptoms, the clinician needs to include a broad consideration of medical, psychosocial, and developmental factors. Examples of issues that can be misconstrued as ADHD symptoms include hearing impairment, specific learning and communication disorders, anxiety, trauma/child abuse, oppositional behavior patterns, and depression. These issues do not by any means exclude the diagnosis of ADHD; they may represent additional problems. However, if the ADHD symptoms are limited to those that can be fully attributed to these issues, then the ADHD diagnosis would not be justified.

— Barry Sarvet, MD
Medical Director, Western Massachusetts MCPAP

Clinical Guidelines:

• Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit Disorder (AACAP):
  Includes table of common behavior rating scales used in the assessment of ADHD and monitoring of treatment.
• Clinical Clinical Practice Guideline: Treatment of the School-Aged Child With Attention-Deficit/Hyperactivity Disorder (AAP):
  Includes table of medications used in the treatment of ADHD and table of effective behavioral techniques for children with ADHD (October 2001 - This policy is more than 5 years old and is no longer considered valid by the AAP.)
• AAP ADHD Toolkit
  The The American Academy of Pediatrics (AAP) ADHD toolkit contains useful information for the diagnosis and treatment of children with attention-deficit/hyperactivity disorder. This resource toolkit contains a wide array of screening, diagnosis, treatment, and support materials for clinicians and other health care professionals, is available for purchase.
• Florida Best Practice Medication Guidelines - Treatment flowchart
- Treatment Flowchart

Screening for ADHD:

Any of the specific ADHD rating scales can be used for screening/early detection.  However, it is more practical to use general mental health and developmental screening instruments for routine surveillance in the primary care setting. 

Examples of general screening instruments that include ADHD symptoms along with other mental health symptoms: (These instruments are approved for compliance and reimbursement within the MassHealth screening initiative.)

35 item questionnaire, public domain, parent report and youth self-report versions, available in multiple languages.

Achenbach System of Empirically Based Assessment (ASEBA): Formerly known as CBCL, 113-item questionnaire, parent report, youth self-report, and teacher report versions generate comprehensive profiles with normed subscales when the instrument is scored; requires data entry for computer scoring or fairly complex hand-scoring. Pre-school starter kit - $230 (Includes manual, software,and 50 forms.) School-Age starter kit - $395 (Includes manual, software, and 50 forms.) Adult starter kit $23. Ongoing costs are as follows: Preschool forms - 50 for $25; SchoolAge forms - 50 for $25 $.50 per form

Rating Scales:

Vanderbilt ADHD Diagnostic Parent/Teacher Rating Scale-Instructions and Scale

• For children 6-12 yrs old
• Parent form: 55 items; Teacher form: 43 items
• 10 minutes to complete
• Parent and teacher complete questionnaire
• Free
• Used for information about symptoms and performance in different settings; not intended for diagnosis.
• Link to parent form
• Link to teacher form

ADHD Rating Scale IV

• For children 6-12
For children 6-12 years old.
• 18 itemsinutes to complete
• Parent, child, and clinicParent, child, and clinician complete questionnaire
• $46 for unlimited copies, manual, parent questionnaires in English and in Spanish;  includes both school and home versions
• For diagnosis and monitoring improvement
• Link to website

ADHD Rating Scale

• For children 6-12 yrs old
• 18 items
• 10-15 minutes to complete
• Parent, teacher, cliniciParent, teacher, clinician, and student complete questionnaire
• Freefor diagnosing ADUseful for diagnosing ADHD and assessing severity;  measures improvements.
• Link to website and tool

Swanson, Nolan, and Pelham (SNAP-IV)

• For children and adolescents 6-18 years old
• 90 items
• 10 minutes to complete
• Parent and teacher complete questionnaire
• Free
• Contains items pertaining to DSM criteria for ADHD; measures impairment and functioning at home and at school
• Form and instructions available at www.ADHD.net

Parent Information and Handouts:

• National Resource Center on ADHD (a program of CHADD)(Children and Adults with Add)
• ADHD Medication Guide
• AAP and National Initiative for Children’s Healthcare Quality Handout
• AACAP Facts for Families: ADHD