ADHD Board Content Specifications

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

1 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 attention- deficit/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

2 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

3 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

4 Core symptoms of ADHD for DSM-V: Hyperactive-impulsive Dimension Inattention Hyperactivity Impulsive Careless mistakes Fidgety Blurts answers before q's completed Difficulty sustaining attention Unable to stay seated Difficulty awaiting turn Seems not to listen Moves excessively Interrupts/intrudes on others Difficult engaging in leisure Fails to finish tasks activities quietely Difficulty organizing "on the go" Avoids tasks that require sustained attention Talks excessively Loses things Easily distracted Forgetful

ADHD Hyperactive-impulsive: 6 ADHD Inattentive: 6 of 9 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 (1- 2cm) Stimulant uncommon side effects:  Hallucinations  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)

5 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 Contraindication Mixed salts of Monoamine oxidase (MAO) inhibitors within 14 days, glaucoma, symptomatic amphetamine 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

References: 1. Floet, AM, Scheiner C, Grossman L. Attention-Deficit/Hyperactivity Disorder. Pediatrics in Review 2010; 31: 56-69.

6 2. Perrin JM, Friedman RA, Knilans TK et al. AAP policy Statement: Cardiovascular Monitoring and Stimulant Drugs for Attention- Deficit/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 Attention- Deficit/Hyperactivity Disorder in Children & Adolescents. Pediatrics 2011; 122 (2): 1007-1022