P EDIATRIC ADHD E VALUATIONS AT FMC

ADHD C RITERIA DSM 5 Children must have ≥ 6 sxs from either or both the inattentive and the hyperactivity and impulsivity criteria Pts age 17 years or older have to have ≥ 5 sxs. Many of sxs have to be present before age 12 No exclusion for people with autism spectrum disorder Must not occur exclusively during a course of psychosis Must not be better explained by another mental disorder.

D IFFERENTIAL D IAGNOSIS OF ADHD G ENERAL MEDICAL CONDITIONS Adverse effects from medication use Allergic rhinitis Asthma Hypothyroidism Infection or trauma Lead toxicity Malnutrition Sensory impairment (vision, hearing) Central nervous system (meningitis)

D IFFERENTIAL DIAGNOSIS OF ADHD N EUROLOGIC CONDITIONS Brain injury Developmental delays Learning disability Mental retardation (fetal alcohol syndrome, fragile X syndrome, phenylketonuria) Seizure disorder Sleep disorder (e.g. obstructive sleep apnea) Speech or language problems

D IFFERENTIAL D IAGNOSIS OF ADHD P SYCHIATRIC CONDITIONS Anxiety Depression Bipolar Disorder Conduct Disorder Oppositional Defiant Disorder Schizophrenia or other psychotic disorders Posttraumatic stress disorder Substance abuse Personality Disorders Adjustment disorders

D IFFERENTIAL D IAGNOSIS OF ADHD E NVIRONMENTAL C ONDITIONS Child neglect, physical or sexual abuse Dysfunctional parenting Hx of bullying or victim of bullying Parental psychopathology or Substance Abuse Social Skills Deficits Socio-cultural factors

FMC E VALUATIONS 1 ST V ISIT 1. ADHD Evaluation: Basic Information Questionnaire & ADHD Screen-parent report (Parent in sub-waiting). 2. BH meets with child and/or parent (depending on development) and administers the following screens. For children age o PHQ-9, GAD-7, and the CRAFFT. For Children 4-10 o CES-DC and the PROMIS. 3. Resident and BH conduct an interview together using the “ADHD Evaluation Interview” as a guideline. 4. Vanderbilts are given to parents if ADHD is a potential Dx.

FMC E VALUATIONS 2 ND V ISIT 1. Pt/family turns Vanderbilts into Front Desk 2. BH scores Vanderbilts 3. BH and Resident discuss scores and review notes from 1 st visit 4. Resident and BH meet with pt/family to discuss treatment plan

P HRAMACOLOGIC T REATMENT Quillivant XR Concerta ** (100) Focalin XR** Ritalin LA **(100) Metadate CD Methylin ER Ritalin SR **(100) Daytrana (patch) Methylphenidate Derivatives Long Acting/Extended Release Methylphenidate Derivatives Short Acting/Immediate Release Focalin **(30) Ritalin **(10) Methylin Methylin Chewable (190) Methylin Solution Vyvanse **(220) Adderall XR **(100) Dexedrine Spansule Adderall **(30) Dextroamphetamine ProCentra Intuniv ** (GuanfacineER) Immediate release 10, extended 275 Kapvay (clonidine ER) Strattera ** (240) Amphetamine Derivatives Long Acting/Extended Release Amphetamine Derivatives Short Acting/Immediate Release Non-Stimulants

B EHAVIORAL T HERAPY Options: FMC Counseling Parent Child Interaction Center Groups will be explored in future. Options: Touchstone Health Partners Parent Child Interaction Center FMC Counseling Parent Skills Training Behavioral Therapy for child

C ASE I LLUSTRATION MOC’s Report: Pt has had difficulty concentrating at school “shuts down”, cries, and hides when he makes mistakes or gets in trouble. Restless, jittery, and doesn’t stop moving until he falls asleep. MOC was not interested in stimulants. She requested Intuniv (guanfacine).

C ASE I LLUSTRATION  Shuts down  Explodes  Cries  Hides  Restless  Difficulty concentrating  High level of energy that last all day. Presenting Problem Education  No prior educational testing  No suspensions/expulsions  Performing well, especially reading  Teachers – Good day = he is on it, he excels and completes tasks. Bad day = he has difficulty concentrating and staying on task.  No complications during pregnancy or delivery  Met all milestones on time.  Trouble making eye contact Lives with MOC, Step-Foc, sister, and 2 step-siblings.  Consistent routines.  Time-outs and occasional spanking.  Recently moved out of chaotic home (grandparents and 10 foster children).  Exposure to emotional abuse  Hx of Family conflict  Strenuous relationship with Bio-father. Early Development Home Environment Family Hx  Sister dx with anxiety and depression  Bio-FOC takes Ritalin  Bio-FOC believed to be an alcoholic Sleep Patterns  No difficulty falling/staying asleep  Nightly nightmares about something bad happening to MOC or being left behind.  Consistent Routine Screening Scores  CES-D = 29 (Significant)  PROMIS = 73 (Severe Anxiety )

F OLLOW - UP CARE Monthly until stable Assess height, weight, heart rate, blood pressure, symptoms, mood, and treatment adherence Adjust dose dependent on symptoms and side effects Monitor at least every three months for side effects of medications if using stimulants Stimulant drug side effect rating scale Growth Drug holidays from stimulants? Encourage behavioral strategies