ADHD and so much more! Improving Management in a PCP’s Office Travis Mickelson, M.D.

Disclosure: The content of this presentation does not relate to any product of a commercial entity; therefore, I have no relationships to report. I will be discussing off-label use medications in pediatric populations.

Clinical Practice Guidelines ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention- Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics 2011:128(5): Refer to: AACAP Practice Parameters

The PCP should… initiate an evaluation for ADHD for any child 4-18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.

ADHD - inattentive Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities Often has trouble holding attention on tasks or play activities Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked) Often has trouble organizing tasks and activities Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework) Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones) Is often easily distracted Is often forgetful in daily activities

ADHD – Hyper/Impulsive Often fidgets with or taps hands or feet, or squirms in seat Often leaves seat in situations when remaining seated is expected Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless) Often unable to play or take part in leisure activities quietly Is often "on the go" acting as if "driven by a motor" Often talks excessively Often blurts out an answer before a question has been completed Often has trouble waiting his/her turn Often interrupts or intrudes on others (e.g., butts into conversations or games)

The PCP should… determine that DSM-V criteria have been met (including documentation of impairment in more than 1 major setting), and information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause.

DSM-5 differs from DSM-IV in the following key areas. DSM-IV TRDSM-5 Age Onset of symptoms Before age 7Before age 12 Symptoms vs. Impairment Impairment in more than one setting Symptoms in more than one setting Age-based Criteria6 of 9 symptoms regardless of age Ages 17 and older, 5 of 9 symptoms

The PCP should… include assessment for other conditions that might coexist with ADHD, including emotional or behavioral (e.g., anxiety, depressive, oppositional defiant, and conduct disorders), developmental (e.g., learning and language disorder or other neurodevelopmental disorders), and physical (e.g., tics, sleep apnea) conditions.

ADHD + Latency Age: Disruptive Behavior – Oppositional and DefiantDisruptive Behavior – Oppositional and Defiant Learning Disorders, Neurocognitive DisordersLearning Disorders, Neurocognitive Disorders Developmental DelayDevelopmental DelayAdolescence: Anxiety – primarily inattentive-type symptomsAnxiety – primarily inattentive-type symptoms Depression – commonly co-occurs with anxiety symptomsDepression – commonly co-occurs with anxiety symptoms Substance UseSubstance Use Vanderbilt – ADHD, ODD, CD, anx/dep, learning d/oVanderbilt – ADHD, ODD, CD, anx/dep, learning d/o MCHAT – Developmental disorders - AutismMCHAT – Developmental disorders - Autism PHQ-A - depressionPHQ-A - depression GAD-7 - anxietyGAD-7 - anxiety CRAFFT – substance useCRAFFT – substance use

The PCP should… recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Management of children and youth with special health care needs should follow the principles of the chronic care model and the medical home.

Psychoeducation regarding ADHD as a chronic condition: Understanding child’s target symptoms and coexisting conditions; how to manage behavior effectively; how to promote healthy peer and family relationships; adherence to treatment. Identifying and addressing family’s goals of care. Identifying and remediating academic strengths and weaknesses. Collaborate with child, family, school to establish measurable target goals. Establish team and coordination plan. ADHD +