“Focusing on the Process” Jeff Schmidt MD

 Recommendation #1: Children ages 4-18 who present with academic underachievement, behavior problems or symptoms of hyperactivity, impulsivity or inattention should be evaluated by PCP Common morbidity of childhood Parents & children will come to primary care regarding these concerns Limited numbers of child psychiatrists nationwide Requires PCP to explore behavior & school performance

 Recommendation #2: Diagnosis requires meeting DSM-V criteria  People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.  Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level.

 Recommendation #2 (cont.): Diagnosis requires meeting DSM-V criteria  Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level.

 Recommendation #2 (cont.):  Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.  Several symptoms are present in two or more setting (e.g. at home, school, or work; with friends or relatives; in other activities)  There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning  The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

 Recommendation #3: Evaluation should include assessment for co-existing conditions  When evaluating for ADHD, assess whether other conditions are present, including › Emotional or behavioral(e.g. anxiety, depressive, oppositional defiant, and conduct disorders), › Developmental (e.g. learning and language disorders or other neurodevelopmental disorders), › Physical (e.g. tics, sleep apnea) conditions.

 Recommendation #4: ADHD should be recognized as a chronic condition, › Care for such children and youth should follow the principles of the chronic care model and the medical home.

 Recommendation #6: Other diagnostic tests not routinely recommended › Lead › Thyroid functions › EEG/MRI etc. › Continuous performance tests  Psychoeducational Testing may be indicated if school history suggestive (rule out learning disability or speech/language problems as the cause of problems or co-existing with ADHD) › Indications: h/o developmental &/or speech delay, unable to read simple words by age 6, two grades behind in subject, screening test in office setting, “spotty” performance across subjects

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 How will my office be set up to be family friendly for behavior & school problems?  How will I obtain a good history?  How will I get DSM-V criteria from parents & teachers and determine if a child meets criteria? › TOOLKIT PROVIDES VANDERBILT  How will I determine if a child has co-existing conditions? › TOOLKIT PROVIDES VANDERBILT  How will I help a family come to terms with the diagnosis?

 Recommendation #1: The treating clinician, parents, and child- in collaboration with school personnel- should specify appropriate goals to guide management.

 Recommendation #2: Recommendations for treatment vary, depending on the child’s age. › A. preschool aged children (4-5): parent or teacher administered behavioral intervention should be the first line of treatment; and medication (methylphenidate) may be considered if first line treatments are not available or insufficient. › B. Elementary school-aged children (6-11): the combination of medication and behavioral interventions have the best outcome. › C. Adolescents (12-18): FDA-approved medications for this age group should be prescribed, preferably along with behavior therapy.

 If medication is prescribed, it should be titrated to ensure the child receives the maximum benefit with the least degree of adverse side effects.

 Recommendation #3: When the selected management for a child with ADHD has not met target outcomes, clinicians should reevaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions.

 Recommendation #4: The clinician should periodically provide systematic follow-up. Monitoring should be directed to the child’s individual goals and any adverse effects of treatment, which information gathered from parents, teachers, and the child.

 How will I educate parents so they can actively participate in the management plan & the ongoing care of their child? › TOOLKIT PROVIDES MANAGEMENT PLAN  How will I titrate medication & using what modalities?  How will I renew prescriptions?  How will I help families access behavioral modification? school services? treatment for co-existing conditions? education about ADHD? › TOOLKIT PROVIDES HANDOUTS  How will I do follow-up & monitoring? › TOOLKIT PROVIDES FORMS

 Who are integral players in the process in the office & community? › Internal: office staff › External: parents, support groups, mental health & school staff, trainees  What specifically will each of them do & do they have the knowledge and skills to do it?  What tools will we use (paper based or computer based questionnaires versus narratives in the office setting) & how will we access those tools?  Where & when will these visits take place?  How will we access needed treatments not provided in our office?

 Schedule appointments  Mail and document that Vanderbilt was sent to family  If urgent-refer to the nurse  On the day of appointment- verify completed packet, if not, have them complete one while waiting

 Obtain and chart weight, height, BP  Generate growth chart  Give packet to MD to review

 Complete assessment  Establish diagnosis  Care plan completed  Referrals completed  Prescriptions  Problem list updated

 Reminds family of 6 month rechecks  Prepares refills for signing  Documents “needs follow-up before next refill”

 Choosing which tools to use: AAP Toolkit, Intermountain MHI packet  Finding Resources: Handouts, websites, therapists and counselor referrals, psych referrals  How to schedule: time allotments, what time of day, follow up visits  Refill of meds procedure