Diagnoses

The U.S. Food and Drug Administration (FDA) has stated that a large, recently completed study in children and young adults treated with medication for ADHD has not shown an association between use of certain ADHD medications and adverse cardiovascular events. Click here for more information.

The AAP does not recommend screening EKGs for patients taking stimulant medications unless the patient's history, family history, or physical examination raises concerns. Click here for more information.

ADHD

Introduction:

Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent psychiatric illnesses for children and adolescents, with prevalence estimated around 3-7 percent. Children and teens with ADHD have significant challenges in academic and social development. The validity of ADHD has been well established and is one the most well-studied and examined neurobehavioral diagnosis. Treatment outcomes for undertreated children continue to be a concern, with evidence of poorer academic achievement, increased drug abuse rates, and motor vehicle accidents. 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 (AAP) and the American Association of Child and Adolescent Psychiatry (AACAP) 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). There are widely available rating scales, such as the Vanderbilt scale, that allow for an efficient method of gathering this information. The AAP guidelines of 2011 reflect the importance of expanded age range from elementary (6-12 y.o.) to include both preschool (4-5 y.o.) and adolescents (13-18 y.o.). The importance of early and continued exploration and screening for ADHD should adjunct development screening throughout the transition stages of toddler, child, teen, and into young adulthood.

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. Many of these issues may coexist with ADHD. These issues do not preclude the diagnosis of ADHD; they might represent additional problems. In many circumstances it is appropriate for the primary care physician to initiate treatment for ADHD and monitor co-morbid behavioral and emotional symptoms.

-Written by Charles Moore, MD, medical director, Southeastern Massachusetts MCPAP and Barry Sarvet, MD, medical director, Western Massachusetts MCPAP

Clinical Guidelines:

Toolkits:

The American Academy of Pediatrics (AAP) ADHD toolkit contains useful information for the diagnosis and treatment of children with ADHD. This resource toolkit contains a wide array of screening, diagnosis, treatment, and support materials for clinicians and other healthcare professionals and is available for purchase. This toolkit has been revised to reflect 2011 changes in the ADHD guidelines. Click here to visit the AAP bookstore.

ADHD Toolkit for the National Intiative for Children's Healthcare Quality

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.

The Pediatric Symptom Checklist listed below is an example of a general screening instrument that includes ADHD symptoms along with other mental health symptoms: (This instrument is approved for compliance and reimbursement within the MassHealth screening initiative.)

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

Rating Scales:

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

For children 6-12 years 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

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

AACAP Facts for Families: ADHD

Family information from the MGH School Psychiatry website

Quality:

Children and youth who receive an initial prescription for ADHD medication must receive at least one follow-up visit with a prescribing practitioner within 30 days of medication initiation. Those who remain on the medication for at least 210 days must receive at least two follow-up visits from 31 to 300 days after the initial prescription. This HEDIS standard is the minimum required for medication monitoring. MCPAP recommends follow-up visits for dose titration, then quarterly visits for monitoring after the initial treatment is optimized.

MCPAP Articles:

Gottlieb, Elaine, ADHD and the New AAP Guidelines, January 2012

Casoli-Reardon, Michele, Towards a Deeper Understanding of ADHD: The Role of Frontal Lobe Dysfunction, March 2011

Updated January 2012