1. Putting ADHD Guidelines Into Practice Through QI Chapter Quality Network ADHD Project Jack Levine, MD, FAAP Chairman, NYS AAP - Chapter 2 Committee on Developmental- Behavioral Pediatrics/Children with Disabiities

2. Jack Levine, MD, FAAP I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved or investigative use of a commercial product/device in my presentation. Commercial Interests Disclosure 2

3.  Review AAP ADHD Guidelines  Identify how to incorporate national ADHD guidelines into daily practice Session Objectives

4. Practice Key Driver Diagram

5.  CQN projects are built on a model.  And the AAP has already provided us with resources. Toward Guideline-Driven Improvement…

6. Our Starting Point AAP Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of ADHD in Children and Adolescents

7. Why are you here? Provide optimal care Mental health interests Like a good challenge  Advantages and Rewards  Provide comprehensive care  Primary care “advantage”  Improve reputation  Attract families  Establish a niche in your office  Expand knowledge  Streamline your approach  Work with other “systems”

8.  Limited payment for what requires more time:  More time with patients/families  Developing relationships with schools  Coordinating care  Limited access to clinicians for referral  Further assessment may not be available through the education system – payer restrictions, insufficient school resources Barriers and Frustrations

9.  And the AAP has already provided us with resources. That’s Why We Are Here!!

10. That sounds doable – right? 6 Key Action Statements

11. 1.The primary care clinician should initiate evaluation 2.Ensure DSM-5 criteria are met 3.Assess for co-existing conditions 4.Follow principles of the chronic care model and medical home 5.Treatment recommendations vary by age 6.Titrate medication Key Action Statement Summary

12. Assessment Visit Treatment Visit Treatment Follow-Up Long-Term Follow-Up

13. Key Action Statement 1: Initiate the Evaluation: Primary Care Clinicians should do this! The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity (quality of evidence B/strong recommendation).

14. Different Presentations of ADHD

15. 2.5 X More Frequent in Boys than Girls Females with predominantly inattentive type Girls are underdiagnosed

16. Key Action Statement 2: Make the Diagnosis 1.Determine that DSM-5 criteria have been met (including documentation of impairment in more than 1 major setting). 2.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. 3.The primary care clinician should also rule out any alternative cause (quality of evidence B/strong recommendation).

17. DSM-5 Criteria For ADHD A.6/9 Inattentive and/or 6/9 Hyperactive/Impulsive Symptoms for longer than 6 months & more common than developmentally expected B.Symptom onset before age 12 C.Symptoms occur in more than one setting D.Symptoms interfere with or reduce the quality of social, academic or occupational functioning E.Symptoms are not better explained by something else

18. Vanderbilt Assessments

19.  Parent and teacher forms  The forms assess:  18 ADHD symptoms  Common comorbidities  Oppositional Defiant Disorder  Conduct Disorder  Anxiety  Depression  Areas of Impairment (e.g., school, peer relations)  Pre-existing conditions (e.g., tics, irritability, externalizing symptoms)  To determine child’s baseline levels of common side effects Vanderbilt ADHD Rating Scales

20. Isn’t this what primary care pediatricians do well every day? Differential Diagnosis

21. Differential Diagnoses (and co-morbidities) MedicalPsychologicalEducational Sleep disorders Seizures Tourette’s/Tics Thyroid Disorders Traumatic Brain Injury Medication Vision or Hearing Issues Anxiety/OCD Depression ODD/CD/IED Autism Spectrum Disorder PTSD Other psychiatric disorders Intellectual Disability LD/Dyslexia Processing Issues Speech/Language Working Memory

22. May not be a DSM-5 Diagnosis or Disorder!  Immaturity (younger for grade)  Attentional variation or problem  Gifted  Hyperactive/impulsive variation or problem  Poor classroom environment, under-challenged  Chaotic home environment (e.g., foster care)  Victim of bullying, trauma  Quirky  Temperamental differences

23. Key Action Statement 3: Assess Co- Morbid/Co-Occurring Conditions  Assessment for other conditions that might coexist with ADHD:  Mental health/Behavioral  Anxiety, depression, oppositional defiant & conduct disorders  Developmental  Learning and language disorders or other developmental disorders  Physical  Tics, sleep difficulty (quality of evidence B/strong recommendation)

24. Assessment Visit Treatment Visit Treatment Follow-Up Long-Term Follow-Up

25. Key Action Statement 4: Treat ADHD as a Chronic Condition ADHD is a chronic condition and should see 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 (quality of evidence B/strong recommendation).

26. FFA Medical Home = Family + MD Community resources and agencies Informed, activated family Integrated, supportive community Based on Wagner et al. Successful Care for CSHCN

27. Key Action Statement 5: Treatment Recommendations Vary by Age Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age:

28.  And Inattention  May not have separate observer  Not as many validated assessment tools Preschoolers often present with Hyperactivity

29. Preschoolers: 4-5 Year Olds a.For preschool-aged children (4–5 years of age), the primary care clinician should prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation)

30. Behavior Therapy – Behavior Modification  Behavior therapy represents a broad set of specific interventions that have a common goal of modifying the physical and social environment to alter or change behavior. Behavior therapy usually is implemented by training parents in specific techniques that improve their abilities to modify and shape their child’s behavior and to improve the child’s ability to regulate his or her own behavior.

31. What is NOT Behavior Therapy?  Psychotherapy  Working with the child  Play therapy  Cognitive-Behavioral Therapy  Bio-feedback  Vision training

32. Finding Behavior Therapy  Resource Guide  Guidelines for Parents and Providers  CAP-PC  Child and Adolescent Psychiatry for Primary Care  http://www.cappcny.org / http://www.cappcny.org /  1-855-CAPPC72 (227-7272)

33. Medication in Preschoolers “...may prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to severe continuing disturbance in the child’s function.” In areas where evidence-based behavioral treatments are not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment (quality of evidence B/recommendation).

34. Preschool ADHD Treatment Study PATS

35.  Behavioral interventions were more effective in preschoolers than in school-aged children and adolescents and didn’t cause side effects.  Medication was effective in preschoolers but not as effective as use of medication in school-aged children and with more side effects than medication use in school aged children.

36. Evidence-Based Behavioral Therapy Intervention Type DescriptionTypical Outcome(s)Effect Size Behavioral parent training (BPT) Behavior- modification principles provided to parents for implementation in home settings Improved compliance with parental commands; improved parental understanding of behavioral principles; high levels of parental satisfaction with treatment.55 Behavioral classroom management Behavior- modification principles provided to teachers for implementation in classroom settings Improved attention to instruction; improved compliance with classroom rules; decreased disruptive behavior; improved work productivity.61

37. HHS Agency for Healthcare Research and Quality 2011 Report  Triple P (Positive Parenting Program)  PCIT (Parent-Child Interaction Therapy)  Incredible Years  New Forest Parenting Programme

38. Elementary School-Aged Children b.For elementary school–aged children (6–11 years of age), the primary care clinician should prescribe US Food and Drug Administration–approved medications for ADHD (quality of evidence A/strong recommendation) and/or evidence- based parent and/or teacher-administered behavior therapy as treatment for ADHD, preferably both (quality of evidence B/strong recommendation).

39. Medication for ADHD  Methylphenidate  d,l-MPH  d-MPH  Amphetamine  Dextroamphetamine  Mixed amphetamine salts – d,l  Lysdexamfetamine  Non-stimulants  Guanfacine  Clonidine  Atomoxetine  Short and Long acting  Delivery system  Combination

40. Stimulants vs Non-Stimulants and 1 more thing  The evidence is particularly strong for stimulant medications and sufficient but less strong for atomoxetine, extended-release guanfacine, and extended-release clonidine (in that order) (quality of evidence A/strong recommendation).  The school environment, program, or placement is a part of any treatment plan. (No quality of evidence sited)

42. Adolescents with ADHD  Procrastination, disorganization, and poor study habits  Academic underachievement, drop out, rule breaking and peer difficulty  Substance abuse, depression, anxiety, risky sexual behavior, teenage pregnancy  Less likely to exhibit overt hyperactive behavior – inattention and impulsivity  Multiple teachers

43. Adolescents: 12 and Up c.For adolescents (12–18 years of age), the primary care clinician should prescribe Food and Drug Administration–approved medications for ADHD with the assent of the adolescent (quality of evidence A/strong recommendation) and may prescribe behavior therapy as treatment for ADHD (quality of evidence C/recommendation), preferably both.

44. Assessment Visit Treatment Visit Treatment Follow-Up Long-Term Follow-Up

45. Key Action Statement 6: Dose titration The primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects (quality of evidence B/strong recommendation).

46.  Weight no longer the determining factor  Start low, go (relatively) quickly  End Points: desired response, minimal side effects Dose Titration: Variation in Individual Response

47. Initiating a Stimulant Trial  Weekly titration recommended: relatively quickly  Regular assessment for medication side effects  Frequent input required from teachers and parents  Use Vanderbilt to get objective information  Typically, use follow-up Vanderbilt (focus on ADHD symptoms)  If co-morbidities, use long Vanderbilt (adds ODD/internalizing questions)  Target optimal dose to defined end-points:  25% drop in Total Symptom Score (Vanderbilt) Nikles et al. Pediatrics; 2006, 117, 2040-2046

48. Side Effects

49. Assessment Visit Treatment Visit Treatment Follow-Up Long-Term Follow-Up

50. Objectives: 1) Maintain symptom reduction 2) Oversee gradual decrease in impairment 3) Monitor for long-term side effects  Once stable, quarterly visits for remainder of school year  Subsequent years: re-assess at least semi-annually, annually  F/U visits should occur 6 – 8 weeks after start of new school year  With all encounters: Obtain teacher and parent rating scales  Encourage/Facilitate obtaining behavioral intervention Ultimate goal: NO IMPAIRMENTS Medication Management: Maintenance

52. MTA Study  “Because stimulants might produce positive but suboptimal effects at a low dose in some children and youth, titration to maximum doses that control symptoms without adverse effects is recommended instead of titration strictly on a milligram-per- kilogram basis.”

53. CONCLUSION  “Evidence continues to be fairly clear with regard to the legitimacy of the diagnosis of ADHD and the appropriate diagnostic criteria and procedures required to establish a diagnosis, identify co-occurring conditions, and treat effectively with both behavioral and pharmacologic interventions. However, the steps required to sustain appropriate treatments and achieve successful long-term outcomes still remain a challenge.”

54. That’s why we’re here!