CONTINUITY CLINIC ADHD Evaluation

CONTINUITY CLINIC "Think of an absentminded professor who can find a cure for cancer but not his glasses in the mess on his desk. These are the inventors, creators, poets -- the people who think creative thoughts because they don't think like everyone else." - Martha Denckla, M.D., Director of the Department of Developmental Cognitive Neurology at the Kennedy- Drieger Institute at John Hopkins speaking on ADHD

CONTINUITY CLINIC Objectives Know the symptoms typical of ADHD Know the symptoms typical of ADHD Be familiar with the common co-morbidities of ADHD Be familiar with the common co-morbidities of ADHD Recognize that the diagnosis of ADHD cannot be made by use of a specific test Recognize that the diagnosis of ADHD cannot be made by use of a specific test

CONTINUITY CLINIC Practice Guidelines Practice Guidelines Primary care clinicians Primary care clinicians Children 6-12 years old Children 6-12 years old Framework for diagnostic decision making Framework for diagnostic decision making Evidence based review Evidence based review

CONTINUITY CLINIC ADHD patients?

CONTINUITY CLINIC Review and Recommendations Strong recommendation: high-quality scientific evidence or strong expert consensus Strong recommendation: high-quality scientific evidence or strong expert consensus Fair/weak: lesser quality, limited data, or expert consensus Fair/weak: lesser quality, limited data, or expert consensus Clinical Options: reasonable provider Clinical Options: reasonable provider

CONTINUITY CLINIC Recommendation #1 Recommendation #1 If inattention, hyperactivity, impulsivity, academic underachievement, behavior problems If inattention, hyperactivity, impulsivity, academic underachievement, behavior problems THEN primary care clinician needs to initiate the evaluation THEN primary care clinician needs to initiate the evaluation Good evidence Strong recommendation Good evidence Strong recommendation

CONTINUITY CLINIC Screening Questions How is __ doing in school? How is __ doing in school? Are there any problems with learning that you/teacher see? Are there any problems with learning that you/teacher see? Is your child happy in school? Is your child happy in school? Are you concerned…behaviors at home/school/play with friends? Are you concerned…behaviors at home/school/play with friends? Is your child having problems completing classwork or homework? Is your child having problems completing classwork or homework?

CONTINUITY CLINIC Recommendation #2 ADHD diagnosis must meet DSM-IV criteria ADHD diagnosis must meet DSM-IV criteria Symptoms and functional impairment Symptoms and functional impairment Criteria remain subjective and no reliable measures in primary care Criteria remain subjective and no reliable measures in primary care Good evidence Strong recommendation Good evidence Strong recommendation

CONTINUITY CLINIC DSM-IV Criteria 6 of 9 symptoms in 2 core areas 6 of 9 symptoms in 2 core areas Inattentive Inattentive Hyperactive/Impulsive Hyperactive/Impulsive Combined (both) Combined (both) causes distress or impairment causes distress or impairment inconsistent with developmental level inconsistent with developmental level

CONTINUITY CLINIC DSM-IV Criteria starts before 7 years old starts before 7 years old lasts over 6 months lasts over 6 months two or more situations (environments) two or more situations (environments) not due to: not due to: Autism, Pervasive Dev Disorder Autism, Pervasive Dev Disorder Mood or Anxiety Disorder Mood or Anxiety Disorder Psychotic Disorder Psychotic Disorder Dissociative or Personality Disorder Dissociative or Personality Disorder

CONTINUITY CLINIC DSM-IV Criteria Inattention 1. fails to give close attention to details, makes careless mistakes in schoolwork or other activities 2. has difficulty sustaining attention to task or play activities 3. does not seem to listen what is said to him/her

CONTINUITY CLINIC DSM-IV Criteria Inattention 4. Does not follow through on instructions; fails to finish schoolwork, chores, duties in workplace (not due to oppositional behavior or failure to understand) 5. difficulty organizing tasks/activities 6. avoids/dislikes tasks that require sustained mental effort

CONTINUITY CLINIC DSM-IV Criteria Inattention 7. loses things necessary for tasks or activities (school assignments, pencils, books, tools, toys) 8. easily distracted by extraneous stimuli 9. forgetful in daily activities

CONTINUITY CLINIC

DSM-IV Criteria Hyperactivity/Impulsivity 1. often fidgets with hands/feet or squirms in seat 2. leaves seat in classroom or in other situations in which remaining seated is expected 3. runs about or climbs excessively where inappropriate (teens or adults may be limited to subjective feelings of restlessness

CONTINUITY CLINIC DSM-IV Criteria Hyperactivity/Impulsivity 4. difficulty playing or engaging in leisure activities quietly 5. talks excessively 6. acts as if “driven by a motor” and cannot remain still

CONTINUITY CLINIC DSM-IV Criteria Hyperactivity/Impulsivity 7. blurts out answers before questions completed 8. difficulty waiting in lines or for turn in games or group situations 9. interrupts or intrudes on others Hyperactive Type ADHD much more common in boys Hyperactive Type ADHD much more common in boys

CONTINUITY CLINIC Recommendation #3 Evidence of core symptoms from parents and caregivers Evidence of core symptoms from parents and caregivers various settings various settings age onset; duration of symptoms age onset; duration of symptoms degree of functional impairment degree of functional impairment Good evidence Strong recommendation Good evidence Strong recommendation

CONTINUITY CLINIC Recommendation #3A Rating scales are an option Rating scales are an option Questions subjective and subject to bias Questions subjective and subject to bias ? If additional benefit ? If additional benefit Strong evidence; strong recommendation Strong evidence; strong recommendation

CONTINUITY CLINIC Recommendation #3B Broad-band scales/questionnaires not recommended Broad-band scales/questionnaires not recommended May be useful for other purposes May be useful for other purposes Strong evidence Strong recommendation Strong evidence Strong recommendation

CONTINUITY CLINIC Recommendation #4 School evidence required School evidence required Core symptoms, duration Core symptoms, duration Functional impairment Functional impairment Coexisting conditions Coexisting conditions Good evidence Strong recommendation Good evidence Strong recommendation

CONTINUITY CLINIC Recommendation #4A Rating scales a clinical option Rating scales a clinical option sensitivity/specificity >94% sensitivity/specificity >94% ? If any added benefit ? If any added benefit Strong evidence Strong recommendation Strong evidence Strong recommendation

CONTINUITY CLINIC Recommendation #4B Global scales not recommended Global scales not recommended May be useful for other purposes May be useful for other purposes Frequent discrepancies Frequent discrepancies Can use other informants Can use other informants Strong evidence Strong recommendation Strong evidence Strong recommendation

CONTINUITY CLINIC Recommendation #5 Assess for coexisting conditions Assess for coexisting conditions ODD 35 % ODD 35 % Conduct Disorder 26% Conduct Disorder 26% Anxiety Disorder 26 % Anxiety Disorder 26 % Depressive Disorder 18% Depressive Disorder 18% Strong evidence Strong recommendation Strong evidence Strong recommendation

CONTINUITY CLINIC Recommendation #6 Other diagnostic tests not routinely indicated Other diagnostic tests not routinely indicated Pb; resistance to thyroid hormone Pb; resistance to thyroid hormone Brain imaging; EEG Brain imaging; EEG Continuous performance testing Continuous performance testing sensitivity/specificity <70% sensitivity/specificity <70% Strong evidence Strong recommendation Strong evidence Strong recommendation

CONTINUITY CLINIC Diagnosis Guidelines Conclusions Use explicit DSM-IV criteria Use explicit DSM-IV criteria Symptoms in >1 setting Symptoms in >1 setting Search for coexisting conditions Search for coexisting conditions