PSP Child and Youth Mental Health

PSP Child and Youth Mental Health
<?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><AllAnswers /> PSP master PowerPoint template specifications Font throughout: Myriad Pro Title font colour: RGB All text font colour: RGB Title slide: Title: 44 font Speaker: 32 font Place and date: 20 font Content slide (positions from top left corner): Title: 32 font; title text box: horizontal 0.56” vertical 0.25” Main text box: horizontal 0.56” vertical 0.25” Footnote: 12 font; horizontal 0.56” vertical 7.25” Font sizes and bullets: see slide 2 PSP slide master specifications Title and ending slides Position of graphics and text from top left corner: Top graphic: horizontal -.01” vertical 0.05” Bottom graphic: horizontal 0” vertical 8.16” PSP logo: horizontal .84” vertical 1” GPSC logo: horizontal 4.49” vertical 7.19” Master title: horizontal 0.56” vertical 3.5” Speaker: horizontal 0.56” vertical 5.08” Date and place: horizontal 0.56” vertical 5.92” Information box: horizontal 1.64” vertical 3.17” Main slides: PSP logo: horizontal 9.28” vertical 7.18” Page number: horizontal 10.14” vertical 7.72” PSP Child and Youth Mental Health Learning Session 3 Presenters name here Location here Date here © 2012 British Columbia Medical Association and Dr. Stanley P. Kutcher. Health educators and health providers are permitted to use this publication for non-commercial educational purposes only. No part of this publication may be modified, adapted, used for commercial or non-educational purposes without the express written consent of the BCMA and Dr. Kutcher.

Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name Relationships with commercial interests: Grants/Research Support: PharmaCorp ABC Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd Consulting Fees: MedX Group Inc. Other: Employee of XYZ Hospital Group Please fill out all applicable areas (highlighted in red). One slide per speaker.

Disclosure of Commercial Support
This program has received financial support from [organization name] in the form of [describe support here – e.g. educational grant]. This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support]. Potential for conflict(s) of interest: [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [enter generic and brand name here]. Please fill out all applicable areas (highlighted in red).

Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to the College of Family Physicians of Canada’s “Quick Tips” document. Please fill out all applicable areas (highlighted in red). Please visit the following link for the CFPC’s “Quick Tips” document:

Some info A few housekeeping items: cells, washrooms. We know emergencies sometimes come up, please feel free to leave the room if you need to take a call The agenda is on the table in front of you. Of importance you will note we are having a break for coffee around: (time) Housekeeping washrooms and nearest fire exist Ground rules Respect all ideas and opinions Share experiences with your peers On time back from break Cell phones on mute or vibrate?

Objectives By the end of this session, you will be able to:
Use appropriate tools to assess and plan a management strategy for child- and-youth-aged patients with ADHD. Use appropriate pharmacological treatment for management of children and youth with ADHD. Develop a care plan to address patients with ADHD that utilizes CYMH tools and resources. Develop a collaborative working relationship with a CYMH team and other community providers (school counselors, specialists, community services, etc.). Identify appropriate community resources to support child-and-youth-aged patients with anxiety, depression, and ADHD.

A mind that is stretched by a new experience can never go back to its old dimensions.
-Oliver Wendell Holmes, Jr.

Child & Adolescent Attention Deficit Hyper Activity Disorder (ADHD)

Fast Facts: Child & Adolescent ADHD
Receives much media attention and controversy. Neuro-developmental psychiatric disorder. Impairs social, academic, family, and occupational functioning. In Canada: 5 – 10 % in youth; 3 – 5 % in adults. Associated with serious mental disorders: Learning Disability Conduct Disorder Oppositional Defiant Disorder Fast Facts about Child and Adolescent Attention Deficit / Hyperactivity Disorder No other psychiatric diagnosis in children receives as much attention from the media and is surrounded by as much controversy as ADHD. ADHD is a neuro-developmental psychiatric disorder that impairs daily social and academic functioning in children. The prevalence of ADHD in Canada is approximately 5 – 8% in children; 5–10 percent, in youth. Children with ADHD are at greater risk than their peers for poorer academic achievement, fewer friends and lower self-esteem. Longitudinal outcome studies of youths with ADHD show increased rates of teen pregnancies, divorce, substance misuse/abuse and other interpersonal difficulties. ADHD is associated with other serious mental disorders such as: Learning Disability, Conduct Disorder, and Oppositional Defiant Disorder. Children diagnosed with ADHD are more prone to physical injury and accidental poisoning. Children with ADHD are more likely to score lower on achievement tests, repeat grades, suffer suspensions and have problems with school. As adolescents they more frequently drop out of school, develop drug and behaviour problems and have more traffic accidents. Early and persistent treatment with effective therapies including medications, psychoeducation and/or behavioural intervention may significantly improve the outcomes of youth with ADHD.

Fast Facts: Child & Adolescent ADHD
Greater risk for: Poorer academic achievement Fewer friends Lower self-esteem Teen pregnancies Substance misuse/abuse Interpersonal difficulties More prone to: Physical injury Accidental poisoning Traffic accidents Fast Facts about Child and Adolescent Attention Deficit / Hyperactivity Disorder No other psychiatric diagnosis in children receives as much attention from the media and is surrounded by as much controversy as ADHD. ADHD is a neuro-developmental psychiatric disorder that impairs daily social and academic functioning in children. The prevalence of ADHD in Canada is approximately 5 – 8% in children; 5–10 percent, in youth. Children with ADHD are at greater risk than their peers for poorer academic achievement, fewer friends and lower self-esteem. Longitudinal outcome studies of youths with ADHD show increased rates of teen pregnancies, divorce, substance misuse/abuse and other interpersonal difficulties. ADHD is associated with other serious mental disorders such as: Learning Disability, Conduct Disorder, and Oppositional Defiant Disorder. Children diagnosed with ADHD are more prone to physical injury and accidental poisoning. Children with ADHD are more likely to score lower on achievement tests, repeat grades, suffer suspensions and have problems with school. As adolescents they more frequently drop out of school, develop drug and behaviour problems and have more traffic accidents. Early and persistent treatment with effective therapies including medications, psychoeducation and/or behavioural intervention may significantly improve the outcomes of youth with ADHD. Upsidedown Vehicle by Bill Longshaw

Typical School Report Card Notes
Stanley [Kutcher] is disruptive in class, he is always talking and has great difficulty sitting still. Stanley cannot settle down to do desk work – he is always fidgeting. Stanley is not getting his homework done, he forgets to take his work home or to bring his homework to school. Stanley’s grades do not reflect what he is capable of doing. Stanley is so disorganized that he will never be successful at anything. Stan’s grade 7 report card.

ADHD Screening Question
Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If YES – consider ADHD Apply the SNAP-IV 18 item scale Proceed to the Identification, Diagnosis and Treatment of the Child and Adolescent ADHD Module Mental Health Screening Q’s Current Situation Over the past few weeks have you been having difficulties with your feelings, such as feeling sad, blah or down most of the time? Over the past few weeks have you been feeling anxious, worried, very upset or are you having panic attacks? Overall, do you have problems concentrating, keeping your mind on things or do you forget things easily (to the point of others noticing and commenting)? If the answer to question 1 is YES – consider a depressive disorder and apply the KADS evaluation and proceed to the Useful Methods for Screening and Diagnosis section for details. If the answer to question 2 is YES – consider an anxiety disorder, apply the SCARED evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth Anxiety Disorders If the answer to question 3 is YES – consider ADHD, apply the SNAP evaluation and proceed to the Identification, Diagnosis and Treatment of Child or Youth ADHD Module NOTE: Note that some cases of anxiety and depression may demonstrate positive scores on the concentration component of the SNAP. If no hyperactivity components are identified on the SNAP review for ADHD, please assess for depression and anxiety using KADS and SCARED. Schoolboy Does Exam Papers

ADHD Screening Tool – Youth Version
Are you able to finish most things that you start within the time others expect? Do you have trouble paying attention to things that are not that interesting to you? Do you fidget or feel you have to move around much of the time? Do you often do things without thinking? Are you having problems at home or school related to your behaviour or because of trouble paying attention? Have these difficulties been there for a long time (six months or longer)? ADHD Screening Tool – Youth Version The following screening questions can be included in clinic/office registration materials to be completed by parents or patients before visits or in the waiting room before the evaluation screening. These tools are provided in the toolkit and clinicians can reproduce them for their clinical use. Question Or Doubt by Jeroen van Oostrom

ADHD Screening Tool – Parent Version
Does your teenager usually not finish things that he or she starts? Is your teenager not able to pay attention to things for as long as other teenagers? Does your teenager fidget or move around much of the time, even when he/she knows she should not? Is your teenager impulsive or does he/she act without thinking much of the time? Is your teenager’s behaviour causing him/her problems at home and at school? Have these difficulties been there for a long time (six months or longer)? ADHD Screening Tool – Parent Version The following screening questions can be included in clinic/office registration materials to be completed by parents or patients before visits or in the waiting room before the evaluation screening. These tools are provided in the toolkit and clinicians can reproduce them for their clinical use. Family by Master isolated images

Step 1: Identification of Risk for ADHD
Well established and significant risk effect Less well established risk effect Possible “group” identifiers (these are not causal for ADHD but may identify factors related to adolescent onset ADHD) A previous diagnosis of ADHD Family history of ADHD Family history of mental disorders (affective, anxiety, tics or conduct disorder) Psychiatric Disorder: Oppositional Defiant Disorder, Conduct Disorder or a Learning Disorder 1. Exposure to severe environmental factors (i.e., lead contamination, prenatal exposure of alcohol and cigarette, birth trauma, low birth weight, head injuries). 2. Psychosocial adversity such as maternal depression, paternal criminality, chaotic home environment, and poverty 3. Substance misuse/abuse (early onset of use including cigarettes and alcohol) 4. Head injury (concussion) School failure or learning difficulties Socially isolated from peers or behavioural problems at home and at school (including gang activity & legal problems) – accident prone. Bullying (victim and/or perpetrator) Identification of Children at Risk for ADHD First contact health providers are in an ideal position to identify children at risk of ADHD. The following table has been compiled from scientific literature and is presented in a format that can be efficiently used by a health provider to identify those young people who should be periodically monitored for onset of ADHD. At Risk Table…

Screening & Diagnosis of ADHD
Approx. 65% of children with ADHD still meet diagnostic criteria during adolescence Child/Adolescent may show: Inattention Distractibility Impulsivity Hyperactivity Requires health provider intervention Differentiate between normal responses to circumstances or developmental changes in normal children Use the “Distress versus Disorder” model Screening & Diagnosis of ADHD (cont’d) Any child may show: inattention, distractibility, impulsivity, or hyperactivity at times, but the child with ADHD shows these symptoms and behaviours more frequently, persistently and severely than other young persons of the same age or developmental level. ADHD will usually require health provider intervention, while normal neuro-developmental changes in cognition or behaviour (such as risk taking, increased over-activity) are usually of short duration (less than a couple of weeks) and are likely to resolve spontaneously or be substantially ameliorated by social support or environmental modification alone. In assessing mental health problems, it is essential to differentiate between signs and symptoms that arise as an expected for normal response to circumstances (e.g., parents return to work, siblings born, house moving, changing school) or developmental changes in normal children (e.g., increased emotional liability in puberty), from those that may signal the onset of a mental disorder. Consider this differentiation using the next model of “Distress versus Disorder”. Freedigitalphotos Africa 31513qkoh8f72ro

Screening & Diagnosis of ADHD
3 Sub-categories: Predominantly Inattentive Predominantly Hyperactive-Impulsive Combined Inattentive/Hyperactive Screening & Diagnosis of ADHD Diagnosis of Attention Deficit / Hyperactivity Disorders is currently made using DSM IV-TR criteria. There are 3 subcategories of ADHD, these are: Predominantly Inattentive subtype (comprising about % of children with ADHD) - manifesting as daydreaming, distractibility and difficulty focusing on a single task for a prolonged period. Predominantly Hyperactive-Impulsive subtype (5 – 10%) - manifesting as situational inappropriate and excessive motor activity such as fidgeting, excessive talking, impulsive actions and restlessness. Combined Inattentive / Hyperactive subtype (60 – 70%) – manifesting as a combination of the above.

Clinical Findings for ADHD Early Childhood 3 – 5 years of age
Difficulty attending to tasks “Squirmy” Difficulties “settling” Very active, always on the go Parents refer to child as: “Not listening” “Zippy” “Always running around” Clinical Findings for ADHD – Early Childhood Some of the clinical findings in early childhood (ages years) are*: The child has difficulty attending, except briefly, to many common interactive or solitary activities such as reading a storybook with their parent or a solitary quiet task such as colouring or drawing. The child is frequently “squirmy” and does not like to sit in one place for any length of time. The child often has difficulties with “settling” which are apparent during times such a naps or when going to bed. The child is described as very active, always on the go, and frequently bumping into things or getting hurt. Parents often refer to the child as “not listening” and “zippy” or “always running around”. dreamstimefree_113773

Clinical Findings for ADHD Middle Childhood 6 – 12 years of age
Child may not persist long with most tasks: Particularly what they do not want to do Parents report child: Does not pay attention or listen Is very forgetful or disorganized Described as: “Overactive”, “always on the go” & “cannot sit still”, Acting out of turn Blurting out in class More evident in situations where attention is expected Clinical Findings for ADHD – Middle Childhood Some of the clinical findings in middle childhood (ages years) are*: The child may not persist very long with most tasks, particularly those they do not want to do such as read an assigned book, homework, or a task that requires concentration such as tidying a room or cleaning something. Parents frequently report that their child does not pay attention, does not listen to them, is very forgetful or disorganized. Parents and teachers describe the child as “overactive”, “always on the go”, “cannot sit still”, acting out of turn, or blurting out an answer in class. These behaviors are more evident in situations where sustained attention and limited motor activity are expected, such as at the dinner table, in a place of religious worship, school classroom, etc. School reports often note that the child is “not living up to their academic potential”. Frequently teachers will note that the child is “not a bad person but is disruptive to the class”. Socially the child may have difficulties with peers based on their impulsivity or intrusiveness. Girls with predominantly inattentive subtype may be identified as daydreamers and may demonstrate academic difficulties based on inattention – especially in subjects requiring persistent concentration such as mathematics. In sports, the child will often be seen to lose attention in the game and may focus on situational irrelevant details of their environment (for example, the outfielder in baseball attends to a rock in the grass and not to the ball that has just been hit into his area of play). Remember, just because a child is very active does not mean that they have ADHD. Also, girls with ADHD may demonstrate predominantly inattentive and not hyperactive symptoms. It is essential to ensure that the symptoms the child is exhibiting meet diagnostic criteria for ADHD, are present across multiple settings (for example: at home; at school; in the playground) and are functionally impairing. Girl With Bunny by Teeratas

Clinical Findings for ADHD Middle Childhood 6 – 12 years of age
School reports, “…not living up to academic potential” Difficulty with peers Impulsivity & intrusiveness An active child does not mean ADHD Girls with ADHD may demonstrate inattentiveness, not hyperactive symptoms Clinical Findings for ADHD – Middle Childhood Some of the clinical findings in middle childhood (ages years) are*: The child may not persist very long with most tasks, particularly those they do not want to do such as read an assigned book, homework, or a task that requires concentration such as tidying a room or cleaning something. Parents frequently report that their child does not pay attention, does not listen to them, is very forgetful or disorganized. Parents and teachers describe the child as “overactive”, “always on the go”, “cannot sit still”, acting out of turn, or blurting out an answer in class. These behaviors are more evident in situations where sustained attention and limited motor activity are expected, such as at the dinner table, in a place of religious worship, school classroom, etc. School reports often note that the child is “not living up to their academic potential”. Frequently teachers will note that the child is “not a bad person but is disruptive to the class”. Socially the child may have difficulties with peers based on their impulsivity or intrusiveness. Girls with predominantly inattentive subtype may be identified as daydreamers and may demonstrate academic difficulties based on inattention – especially in subjects requiring persistent concentration such as mathematics. In sports, the child will often be seen to lose attention in the game and may focus on situational irrelevant details of their environment (for example, the outfielder in baseball attends to a rock in the grass and not to the ball that has just been hit into his area of play). Remember, just because a child is very active does not mean that they have ADHD. Also, girls with ADHD may demonstrate predominantly inattentive and not hyperactive symptoms. It is essential to ensure that the symptoms the child is exhibiting meet diagnostic criteria for ADHD, are present across multiple settings (for example: at home; at school; in the playground) and are functionally impairing.

Clinical Findings for ADHD Adolescence 13 – 19 years of age
Easily distracted from tasks. Feelings of inner restlessness. Stopping short on tasks. Forgetful; fail to complete tasks. Fidgety. Difficulty with relationships. Many “breakups”. Impaired temper control. Impulsive decision making. Clinical Findings for ADHD – Adolescence Some of the clinical findings in the adolescence (ages years) are*: Easily distracted from tasks they do not want to perform; Feelings of inner restlessness; Frequently the teen with ADHD will stop short on task behaviors (for example: they may begin washing the car and stop part of the way through to go play a game with their friends), making it difficult to be successful at activities that demand prolonged sustained attention, such as homework; They will often appear very forgetful and frequently will fail to complete simple tasks at home and at school; They tend to be fidgety; Socially they may have difficulties in interpersonal relationships and may have more frequent “breakups”; Impaired temper control, or impulsive decisions making; They engage in “risky” behavior, are at higher risk for traffic accidents and are often considered by adults to “lack maturity” compared to others of the same age; If the young person has not been diagnosed and treated, they may exhibit signs of demoralization due to what they perceived to be negative comments or “nagging” from parents, teachers, other adults and peers. This demoralization should not be confused with depression; Teens with ADHD may get involved with youth who are focused on drug use and possibly criminal behaviors; Early school leaving may be seen, particularly if a learning disability is present but has not been identified and remediated. * These must be persistent, substantial and impairing! Glamour by federico stevanin

Clinical Findings for ADHD Adolescence 13 – 19 years of age
Engage in “risky” behavior: At higher risk for traffic accidents Considered “lacking maturity” for their age. Without treatment, exhibit signs of demoralization: Due to negative comments “Nagging” from parents, teachers, adults and peers Do not confuse demoralization with depression May get involved in drug use and criminal behavior. School drop outs, especially with unidentified learning disability. Clinical Findings for ADHD – Adolescence Some of the clinical findings in the adolescence (ages years) are*: Easily distracted from tasks they do not want to perform; Feelings of inner restlessness; Frequently the teen with ADHD will stop short on task behaviors (for example: they may begin washing the car and stop part of the way through to go play a game with their friends), making it difficult to be successful at activities that demand prolonged sustained attention, such as homework; They will often appear very forgetful and frequently will fail to complete simple tasks at home and at school; They tend to be fidgety; Socially they may have difficulties in interpersonal relationships and may have more frequent “breakups”; Impaired temper control, or impulsive decisions making; They engage in “risky” behavior, are at higher risk for traffic accidents and are often considered by adults to “lack maturity” compared to others of the same age; If the young person has not been diagnosed and treated, they may exhibit signs of demoralization due to what they perceived to be negative comments or “nagging” from parents, teachers, other adults and peers. This demoralization should not be confused with depression; Teens with ADHD may get involved with youth who are focused on drug use and possibly criminal behaviors; Early school leaving may be seen, particularly if a learning disability is present but has not been identified and remediated. * These must be persistent, substantial and impairing!

Youth ADHD Screening Q’s
Inquire about substance misuse/abuse: Including marijuana - Youth with ADHD may be more likely to use a variety of substances Specialist consultation for substance abuse & ADHD Youth ADHD Screening Questions If the screening questions above identify three or more positive answers, enquire about SUBSTANCE MISUSE / ABUSE (especially marijuana). Remember that youth with ADHD may be more likely to use a variety of substances, so the presence of substance misuse/abuse does not mean the youth does not have ADHD. In complex situations (such as substance abuse and ADHD), specialist consultation is suggested. Following on, it is reasonable to move ahead to a focused history and diagnostic assessment using the SNAP-IV Teacher and Parent 18-item Rating Scale as follows. Special attention should be given to assessing school performance and behavior at home and at school. stockxchng ID

Don’t Get Overwhelmed!! Assessment of ADHD
An appropriate assessment of ADHD can be completed in three to four 15-minute office visits using the suggested framework below. Some clinicians may prefer to integrate the details found in the suggested tools into their assessment interviews rather than using the tools separately. REMEMBER: Treatment of ADHD is not an emergency. Take your time and make sure of the diagnosis and that the parents and child are informed and understand the disorder and its treatment. Assessment of ADHD Four 15 minute office visits Treatment is NOT an emergency Take your time Ensure diagnosis is correct Dreamstimefree

SNAP-IV Teacher and Parent 18-item Rating Scale
Assessment Tool SNAP-IV Teacher and Parent 18-item Rating Scale A norm-referenced checklist DSM-IV criteria for ADHD Diagnosis of ADHD in Childhood using the SNAP-IV The SNAP-IV Teacher and Parent 18-item Rating Scale is a norm-referenced checklist that is designed to determine the presence of ADHD symptoms. The SNAP-IV can be used by any clinician assessing a young person for ADHD. This checklist can also be completed by either a parent or other caregiver or an educator for use by a healthcare provider in performing an assessment. One method of evaluating the SNAP-IV is to look at subscale scores. Subscale scores on the SNAP-IV are calculated by summing the scores on the items in the specific subset (e.g., Inattention) and dividing by the number of items in the subset (e.g., 9). The score for any subset is expressed as the Average Rating Per Item. The 5% cutoff scores for teachers and parents are provided. Compare the Average Rating Per Item score to the cut-off score to determine if the score falls within the top 5%. Scores in the top 5% are considered significantly different from “usual”. To meet DSM-IV criteria for ADHD, there must be at least 6 responses of "Quite a Bit" or "Very Much" (scored 2 or 3) to either the 9 inattentive items (1-9) or 9 hyperactive-impulsive items (10-18), or both on the SNAP-IV 18 item Rating Scale.

SNAP-IV Teacher and Parent 18-item Rating Scale
Assessment Tool SNAP-IV Teacher and Parent 18-item Rating Scale Young person must meet the following criteria: Some symptoms present before age 7 years Some impairment present in two or more settings Clear evidence of clinically significant impairment Diagnosis of ADHD in Childhood using the SNAP-IV In addition to the SNAP-IV score, a young person with a diagnosis of ADHD must also meet the following criteria : Some symptoms that caused impairment were present before age 7 years Some impairment from the symptoms is present in two or more settings (e.g., school, work, home) There must be clear evidence of clinically significant impairment in social, academic or occupational functioning The impairment must not be primarily due to any other factors or conditions (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorders, or a Personality Disorder).

Assessment Tool SNAP-IV Teacher and Parent 18-item Rating Scale
Rating scale alone not sufficient to diagnose For diagnosis and clinical intervention must have: Complete history Appropriate physical examination Ensure DSM-IV-TR criteria is met Diagnosis of ADHD in Childhood using the SNAP-IV Depending on the domains affected, ADHD can be predominantly inattentive type; predominantly hyperactive-impulsive type; or combined type. Using a rating scale such as this alone, however, may not be sufficient in and of itself to diagnose ADHD, since the diagnosis of ADHD should be based on a thorough clinical assessment. A complete history and appropriate physical examination, if indicated, are necessary for diagnosis and clinical intervention. Ensure that the child meets the DSM-IV-TR criteria for ADHD before proceeding to treatment. If a SNAP-IV Teacher and Parent 18 item Rating Scale score of 18 or higher is found during screening: Have a discussion about important issues/problems in the child’s life/environment. Complete or use the Child Functional Assessment (CFA) to assist in determining the impact of the ADHD on the child’s functioning. * The SNAP-IV 18 item plus a thorough clinical assessment is sufficient to make an ADHD diagnosis as this clinical tool contains all of the DSM-IV TR criteria for ADHD.

Assessment Tool What to do if a SNAP-IV score of 18 or higher
SNAP-IV Teacher and Parent 18-item Rating Scale What to do if a SNAP-IV score of 18 or higher Diagnosis of ADHD in Childhood using the SNAP-IV Depending on the domains affected, ADHD can be predominantly inattentive type; predominantly hyperactive-impulsive type; or combined type. Using a rating scale such as this alone, however, may not be sufficient in and of itself to diagnose ADHD, since the diagnosis of ADHD should be based on a thorough clinical assessment. A complete history and appropriate physical examination, if indicated, are necessary for diagnosis and clinical intervention. Ensure that the child meets the DSM-IV-TR criteria for ADHD before proceeding to treatment. If a SNAP-IV Teacher and Parent 18 item Rating Scale score of 18 or higher is found during screening: Have a discussion about important issues/problems in the child’s life/environment. Complete or use the Child Functional Assessment (CFA) to assist in determining the impact of the ADHD on the child’s functioning. Youth: Screen for Depression Use the Kutcher Adolescent Depression Screen (KADS) Complete or use the Teen Functional Activities Assessment (TeFA) to determine the impact on functioning * The SNAP-IV 18 item plus a thorough clinical assessment is sufficient to make an ADHD diagnosis as this clinical tool contains all of the DSM-IV TR criteria for ADHD.

Monitoring and Intervention Tools: ADHD
CGI TeFA / CFA TASR-A SNAP-IV Interventions (these do not replace medications or psychotherapies) PST WRP

Children Visit 1 Visit 2 SNAP-IV 18 item Consider risk factors
If risk factors are substantial or if three or more positives answers on either the Parent or Child Version of the Screening Tool or CFA suggests dysfunction due to ADHD like symptoms - Use the Psychotherapeutic Support for Children (PSC) and Stress Reduction Prescription (WRP) (proceed to step 2 in weeks.) Complete SNAP-IV. Provide SNAP-IV to parents and teachers. Provide information about ADHD and its treatment. Obtain informed consent to allow discussion with the school. Visit 1 Consider risk factors Apply screening tool Complete CFA Complete SNAP-IV If fewer than 3 positive answers on The Parent or Adolescent version of the Screening Tool - consider other possible explanations for signs/symptoms such as: environmental stressors, Oppositional Defiant Disorder, Conduct Disorder, Learning Disorder. Use the Psychotherapeutic Support for Children (PSC) and Worry Reduction Prescription (WRP) and monitor again in a month and repeat STEP I and review other possible psychiatric conditions. If SNAP-IV 18 > 18 (or a mean score of greater than 1) and CFA shows decrease in function - continue with PST and WRP strategies - proceed to step 3 within a week. Review SNAP-IV from parents and teachers for scores as above. Discuss ADHD and its treatment and encourage “google search”. * Using the algorithm, speak to these points instead of showing this slide * Clinical Approach 3 Step Process Visit 2 SNAP-IV 18 item CFA Use PST and WRP If SNAP-IV 18 <18 (or a mean score of greater than 1) and shows no decrease in function – continue with PST and WRP strategies and monitor again in a month – advise to call if feeling worse or problems escalate.

Children If SNAP-IV 18 remains > 18 (or a mean score of greater than 1) and CFA shows functioning problems – proceed to diagnosis (review DSM-IV-TR criteria) and treatment after discussion of ADHD and treatment options** Visit 3 SNAP-IV 18 CFA Use PST and WRP If SNAP-IV 18 <18 (or a mean score of greater than 1) and CFA shows no decrease in function – continue with PST and WRP strategies - monitor again with SNAP-IV 18 and CFA in one month – advise to call if feeling worse or problems escalate. Consider Strongest Families BC. * Using the algorithm, speak to these points instead of showing this slide * Clinical Approach 3 Step Process Download Two Girls On A Swing by Naypong

Apply screening tool TeFA
If risk factors are substantial or if two or more positives answers on either the Parent or Adolescent Version of the Screening Tool or TeFA suggests dysfunction due to ADHD like symptoms - Use Psychotherapeutic Support for Teens (PST) and Worry Reduction Prescription (WRP) , see page 21 - proceed to step 2 in weeks Provide SNAP-IV to parents and teachers (school contact can be through parents if feasible). Complete SNAP-IV 18. Provide information about ADHD and its treatment. Obtain informed consent to allow discussion with the school. Youth Visit 1 Consider risk factors Apply screening tool TeFA SNAP-IV If fewer than 3 positive answers on The Parent or Adolescent version of the Screening tool - consider other possible explanations for signs/symptoms such as: environmental stressors, Oppositional Defiant Disorder, Conduct Disorder, Learning Disorder. Use PST (see page 29) and WRP (see page 21) and monitor again in a month and repeat STEP I and review other possible psychiatric conditions. If SNAP-IV 18 > 18 (or a mean score of greater than 1) and TeFA shows decrease in function - continue with PST and WRP strategies - proceed to step 3 within a week. Review SNAP-IV 18 from parents and teachers for scores as above. Discuss ADHD and its treatment and encourage “google search”. * Using the algorithm, speak to these points instead of showing this slide * Clinical Approach 3 Step Process * Each tool above is found in the toolkit. ** Providing parents and young people with evidence based information about ADHD and treatment options is essential. There is much misinformation and disinformation about ADHD widely available in the public domain – not only on anti-ADHD websites such as those supported by Scientology or purveyors of products and programs, but also in the main stream media. It is very important that parents and young people engage with information that is incorrect, biased or deliberately misleading and that they do so in an informed and supported manner. Your assistance in this activity is important. One useful resource for parents and youth to help them better understand and evaluate what they read and hear about is Evidence Based Medicine (versions for parents and youth) that can be accessed at Visit 2 SNAP-IV 18 item TeFA Use PST and WRP If SNAP-IV 18 <18 (or a mean score of greater than 1) and shows no decrease in function – continue with PST and WRP strategies and monitor again in a month– advise to call if feeling worse or problems escalate.

Youth If SNAP-IV 18 remains > 18 (or a mean score of greater than 1) and TeFA shows decrease in function – proceed to diagnosis (review DSM-IV-TR criteria) and treatment. Visit 3 SNAP-IV 18 TeFA Use PST and WRP If SNAP-IV 18 <18 (or a mean score of greater than 1) and TeFA shows no decrease in function – continue with PST and WRP strategies - monitor again with SNAP-IV 18 and TeFA in one month – advise to call if suicide thoughts or acts of self-harm occur or if problems escalate. * Using the algorithm, speak to these points instead of showing this slide * Clinical Approach 3 Step Process * Each tool above is found in the toolkit. ** Providing parents and young people with evidence based information about ADHD and treatment options is essential. There is much misinformation and disinformation about ADHD widely available in the public domain – not only on anti-ADHD websites such as those supported by Scientology or purveyors of products and programs, but also in the main stream media. It is very important that parents and young people engage with information that is incorrect, biased or deliberately misleading and that they do so in an informed and supported manner. Your assistance in this activity is important. One useful resource for parents and youth to help them better understand and evaluate what they read and hear about is Evidence Based Medicine (versions for parents and youth) that can be accessed at freedigitalphotos Sujin Jetkasettakorn

Co-morbidity in ADHD Approx. 30 – 50% of people with ADHD have other psychiatric disorders: Oppositional Defiant Disorder (ODD) Conduct Disorder (CD) Learning Disorder Co-morbidity in ADHD A brief, focused assessment of common co-morbidities in ADHD should be part of the ADHD assessment. Approximately 30-50% of people with ADHD have other psychiatric disorders. Information from the parent can help identify Oppositional Defiant Disorder (ODD), Conduct Disorder (CD) or a learning disorder (diagnostic criteria below). A discussion with the teacher or guidance counsellor will be necessary to both obtain an independent assessment of behaviours at school and to address the possibility of a learning disability. Specialized learning assessments are often available through the school and these can usually be initiated by the parent. In many cases, input from the primary care physician or primary health care team member can be useful as part of the learning assessment. Remember that when engaging with the school to obtain the proper informed consent from parent and/or assent from the child prior to discussions with the school. Oppositional Defiant Disorder (ODD) Conduct Disorder (CD) Learning Disorder (LD) When patients with ADHD meet DSM-IV-TR criteria for a second disorder, the clinician should develop a treatment plan to address each of these as well (such as ODD or CD), in addition to the ADHD. However, the ADHD should be treated first as clinically the co-morbid disorder often demonstrates improvement as the ADHD improves.

Co-morbidity in ADHD Begin treatment
Refer child/youth to specialty services or Stronger Families If learning disability is suspected: Refer for educational psychological testing Contact school Remedial learning strategies Informed written consent to contact school Co-morbidity in ADHD In primary care practice, it is reasonable to begin treatment for the ADHD symptoms and refer the child or youth for more intensive behavioral or family interventions to specialty services if they are available. Most young persons with ADHD co-morbid with ODD, CD or LD will require specialty mental health care. In such cases the primary care provider should be part of the treatment team. If a learning disability is suspected, then a referral for educational psychological testing should be made and the clinician should contact the child’s teacher or school counselor to ensure that educators are aware of this issue as remedial learning strategies can often be put into place before a full learning assessment has been conducted. Ensure that you have obtained informed written consent to contact the school from the parents. In some school jurisdictions, requests for psycho-educational testing must originate from or be supported by the parents or official guardian. A sample letter requesting psycho-educational testing from the school is found in the ADHD Toolkit. by Salvatore Vuono

Pharmacological Treatment of Child & Adolescent ADHD

Baseline Measurement CBC Complete blood count (CBC)
WFIRS\P CFA CBC Ht Wt BP Pulse SNAP-IV 18 History KSES-A Complete blood count (CBC) Height; Weight; Blood Pressure; Pulse Rate SNAP-IV 18 Items Rating Scale WFIRS-P (Weiss Functional Impairment Rating Scale- Parent Report) CFA (Child Functional Assessment) KSES-A (Kutcher Side Effects Scale for ADHD Meds) Family history of heart disease Baseline Measurement Once you have conducted an assessment, diagnosed ADHD, started the non-specific interventions and both parties agree on the use of medication, then you are ready to begin medication treatment. Remember, treatment of ADHD is not an emergency. Prepare the ground before you begin. This will help avoid adherence difficulties later. The first thing to do is to obtain baseline measurements of symptoms and physical complaints as this will allow you to provide a more accurate clinical and functional follow up as well as ongoing monitoring of the presence and severity of symptoms and any treatment emergent adverse events. Baseline measurement should include: Complete blood count (CBC) Height; Weight; Blood pressure; and Pulse rate SNAP-IV 18 items Rating Scale CFA (Child Functional Assessment) KSES-A (Kutcher Side Effects Scale for ADHD Medication) Inquire about a history of heart diseases (patient & family). Past history or family history of heart disease or a family history of sudden death a cardiology consultation should be obtained prior to initiating treatment. Treatment monitoring should include bi-annual height and weight determinations Medications for ADHD fall into two categories: Stimulants and Non-Stimulants. Stimulants have been successfully used for many decades, yet much misinformation (including much disinformation) about them persists.

Facts About Stimulants
Do not cause addiction in ADHD treatment Tolerance develops occasionally Decreases rates of future substance abuse Improves outcomes in functioning “Drug holidays” are not needed Long acting, once per day dose easiest Facts about stimulants Stimulants used for ADHD do not cause addiction! Tolerance may develop occasionally in some patients. Medications should not be used just to improve grades or quiet classroom behavior. Medications should be used to treat ADHD. Stimulant treatment of ADHD in childhood decreases rates of future substance abuse. Research shows the opposite to be true. Overall, stimulants are a safe treatment. Long-term treatment with stimulant medications at proper doses is associated with significantly improved outcomes across multiple domains of functioning, “Drug holidays” are not needed unless there are substantive decreases in growth or weight trajectories. The use of long acting once daily dosing preparations may be easiest for the patient and family to use and may improve compliance with treatment. www. Freedigitalphotos by Danilo Rizzuti

Stimulants & Non-Stimulants
Highly effective Available for decades Well studied Safe prescribed to healthy patients under medical supervision For youth… Not responding well to stimulant medications At risk for substance abuse With other conditions with ADHD Available in two different forms Short-Intermediate Release Preparations Repeated doses/day More adverse effects Stigma associated with taking at school. Methylphenidate’s Ritalin® Ritalin® SR PMS or Ratio Methylphenidate Dextroamphetamine Sulphate’s Dexedrine Extended Release Preparations Preferred over short-acting medications, Better compliance; less diversion. More expensive, not all Canadian medication insurance plans cover. Mixed Salts Amphetamine *Adderall XR Methylphenidate *Biphentin *Concerta *Novo-Methylphenidate ER-C Lisdexamfetamine Dimesylate *Vyvanse Atomoxetine *Strattera Is the only non-stimulant medication that is approved to treat children / adolescents with ADHD. Stimulants& Non-Stimulants ADHD medications are grouped into two major categories: stimulants and non-stimulants. Now you have to decide whether your patient will benefit by receiving a stimulant or a non-stimulant medication. The chart above shows some points to help you make that decision:

Additional ADHD Medications
Tricyclic antidepressants (not recommended) Imipramine or Desipramine Bupropion Wellbutrin Clonidine Reserve these medications for specialty mental health services Additional ADHD Medications Used There are some other medications that can be tried as ADHD treatment including tricyclic antidepressants (Imipramine or Desipramine) or bupropion (Wellbutrin), Clonidine is also sometimes used. It is recommended that these medications be reserved for use by specialized mental health services. by Wishedauan

“N of 1” Model Evaluating response to Methylphenidate
3-day baseline assessment SNAP-IV 18 Alternate every 3 days for 12 days: Dose of methylphenidate (standard release) 5 mg/BID or 10 mg/BID depending on weight Dose of placebo Daily measurement Symptoms (SNAP-IV 18) Side Effects (KSES-A) “N of 1” Model to Assist in Evaluating the Response to Methylphenidate There is a type of clinical protocol that is especially useful in those cases in which the patient or parent has serious concerns about the value of pharmacological treatment for ADHD. The protocol is based on Methylphenidate’s rapid onset and offset pharmacodynamics. Following a 3-day baseline assessment of symptoms (SNAP-IV 18) a standard dose of methylphenidate standard release (2.5mg P.O. T.I.D or 5.0 mg P.O., T.I.D. – depending on weight of the child) is given alternatively with placebo, each over an alternating 3 - day period for a total of 12 days. Measurement of symptoms (SNAP-IV 18) and side effects (KSES-A) should be obtained on a daily basis. If the results suggest a medication effect then the optimal dosage should be reached as it is indicated below. Once it has been reached we suggest switching to a methylphenidate extended released form. Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 No Medication 5 -10mg/bid 5 - 10mg/bid Placebo Medication 5-10mg/bid

Stimulants Missuse Concerning with alcohol/drug abuse
Careful evaluation and monitoring Avoiding drug diversion Sustained-release preparations Non-stimulants Consider using Atomoxetine Studying for exams Stimulants Misuse Stimulants can be misused, however abuse of stimulants is not a significant concern in patients without a history of alcohol or drug abuse. Young people with histories of alcohol or drug abuse require careful evaluation and monitoring when prescribed stimulants to ensure that they are taking the medication as prescribed and avoiding drug diversion (using the medication recreationally or providing it to others). Some adolescents may feign ADHD symptoms, to obtaining psychostimulant drugs either to sell them or help them study more effectively or simply use them as party drugs. Sustained-release preparations or non-stimulants may help to mitigate some of the diversion potential. If a child or adolescent has a history of drug or alcohol abuse, or if a parent or other person with access to the medication has such a history of or is currently abusing drugs or alcohol, the use of Atomoxetine should be considered. by Africa

Methylphenidate Treatment
START LOW & GO SLOW Begin: 2.5mg – 5mg; morning and noon; 30 – 45 minutes before meals. Maintain for 1 wk. If insufficient effect, tolerable and no significant side effects increase to 5mg - 10mg in morning and 2.5mg - 5mg at noon and maintain for a week If needed, increase: to 5 mg – 10mg in the morning and 5mg – 10mg at noon. Maintain for 1 wk. If insufficient effect, tolerable and no significant side effects increase: to 5 mg – 10mg in the morning, 5mg – 10 mg at noon and 2.5 – 5mg at 4pm. Maintain for 1 wk. Continue stepped titration by 2.5mg - 5mg weekly to a maximum total daily dose of 2mg/kg/d not to exceed 60 mg, measuring outcomes every week following the step increase. After beginning dose and increases: Measure outcomes using SNAP-IV 18 items (aiming for a score of less than or equal to 18) and the KSES-A If Side Effects… …become a problem, while no substantial improvement, increase time between increases from 1 wk to 2 wks; continue steps. …limit dose increases to optimize symptom control, refer to specialty services or change to Dextroamphetamine . Discontinuation: Taper gradually over several months at low stress times Initiating and Continuing Methylphenidate Treatment Reaching the optimal therapeutic daily dose may take two weeks or more if dose adjustment occurs weekly. If adequate symptom control has not been reached at a total daily dose of 60 mg of methylphenidate specialist consultation is indicated. Start low and go slow. Begin at 5 mg in the morning and 5 mg four to five hours later and 5 mg at dinner, preferably 30 – 45 min before meals and maintain for one week. Measure outcomes using SNAP-IV 18 items and KSES-A. If symptoms are not under optimal control, increase to 10 mg in the morning and 10mg four to five hours later and 10mg at dinner and maintain for one week. If symptoms are not under optimal control, increase to 15 mg in the morning, 15 mg four to five hours later 15mg at dinner and maintain for one week. If symptoms are not under optimal control, increase to 20 mg in the morning, 20 mg four to five hours later and 20mg at dinner and maintain for one week. Continue this stepped titration to a SNAP-IV score of less than or equal to 1 to a maximum total daily dose of 60 mg, measuring outcomes every week following the step increase. If at any time during this stepped upward titration side effects become a problem while symptoms are not showing substantial improvement, increase the time between increases from one week to two weeks and continue the steps. If side effects limit dose increases to optimize symptom control, refer to specialty services or change to Atomoxetine. *Once substantive symptom improvement as per the SNAP-IV 18 and parent plus teacher report has been obtained; discontinue upwards titration and use as the daily target dose.

Dextroamphetamine Treatment
START LOW & GO SLOW Begin: 2.5 mg – 5mg in the morning and 2.5mg – 5mg at noon; 30 – 45 minutes before meals. Maintain for 1 wk. If insufficient effect, tolerable and no significant side effects increase to 5 mg - 10mg in morning and 2.5mg - 5mg at noon and maintain for a week If insufficient effect, tolerable and no significant side effects increase to 5 mg - 10mg in morning and 5mg - 10mg at noon and maintain for a week If insufficient effect, tolerable and no significant side effects increase: to 5mg - 10mg in the morning and 5mg – 10mg at noon and 2.5mg – 5mg at 4pm. Maintain for 1 wk. Continue stepped titration by 2.5mg – 5mg weekly to a maximum total daily dose of 20 mg, - 40mg measuring outcomes every week following the step increase. After beginning dose and increases: Measure outcomes using SNAP-IV 18 items (aiming for a score of less than or equal to 18) and the KSES-A If Side Effects… …become a problem, while no substantial improvement, increase time between increases from 1 wk to 2 wks; continue steps. …limit dose increases to optimize symptom control, refer to specialty services or change to Methylphenidate if not tried yet or consider Atomoxetine . Discontinuation: Taper gradually over several months at low stress times Initiating and Continuing Methylphenidate Treatment Reaching the optimal therapeutic daily dose may take two weeks or more if dose adjustment occurs weekly. If adequate symptom control has not been reached at a total daily dose of 60 mg of methylphenidate specialist consultation is indicated. Start low and go slow. Begin at 5 mg in the morning and 5 mg four to five hours later and 5 mg at dinner, preferably 30 – 45 min before meals and maintain for one week. Measure outcomes using SNAP-IV 18 items and KSES-A. If symptoms are not under optimal control, increase to 10 mg in the morning and 10mg four to five hours later and 10mg at dinner and maintain for one week. If symptoms are not under optimal control, increase to 15 mg in the morning, 15 mg four to five hours later 15mg at dinner and maintain for one week. If symptoms are not under optimal control, increase to 20 mg in the morning, 20 mg four to five hours later and 20mg at dinner and maintain for one week. Continue this stepped titration to a SNAP-IV score of less than or equal to 1 to a maximum total daily dose of 60 mg, measuring outcomes every week following the step increase. If at any time during this stepped upward titration side effects become a problem while symptoms are not showing substantial improvement, increase the time between increases from one week to two weeks and continue the steps. If side effects limit dose increases to optimize symptom control, refer to specialty services or change to Atomoxetine. *Once substantive symptom improvement as per the SNAP-IV 18 and parent plus teacher report has been obtained; discontinue upwards titration and use as the daily target dose.

Non-Stimulant Atomoxetine Treatment
START LOW & GO SLOW Begin: 0.5 mg/kg/d in the morning for 2 wks Increase: to 0.8 mg/kg/d in the morning for 2 wks Increase: to 1.0 mg/kg/d in the morning for 2 wks After beginning dose and increases: Measure outcomes using SNAP-IV 18 items (aiming for a score of less than or equal to 18) and the KSES-A If Side Effects… …become a problem, while no substantial improvement, increase time between increases to 4 wks …limit dose increases to optimize symptom control, refer to specialty services. …and symptoms are not under optimal control, increase to 1.2mg/kg/d in the morning; maintain for a period of 2 wks. Measure outcomes using SNAP-IV 18 items and the KSES-A. Discontinuation: Taper gradually over several months at low stress times NOTE: If symptoms are not under optimal control with 1.2mg after maintaining it for at least 6 weeks refer to speciality service. Initiating and Continuing Non-Stimulant (Atomoxetine) Treatment The therapeutic effects of atomoxetine may take weeks to be appreciated. Atomoxetine (Strattera) should be taken for 6–8 weeks before deciding whether it is effective or not. Many people respond to atomoxetine who don't respond to stimulants. Its advantage over stimulants for the treatment of ADHD is that it has less abuse potential than stimulants. Start low and go slow. Begin with 0.5mg/kg/d in the morning and maintain for a period of 2 weeks. Measure outcomes using SNAP-IV 18 items (aiming for a score of less than or equal to 18) and the KSES-A. Increase to 0.8mg/kg/d in the morning and maintain for a period of 2 weeks. Increase to 1 mg/kg/d in the morning and maintain for a period of 2 weeks. If at any time during this stepped upward titration side effects become a problem while symptoms are not showing substantial improvement, increase the time between increases from 2 to 4 weeks and continue the steps. If side effects limit dose increases to optimize symptom control, refer to specialty services. If symptoms are not under optimal control, increase to 1.2mg/kg/d in the morning and maintain for a period of 2 weeks. Measure outcomes using SNAP-IV 18 items and the KSES-A. If symptoms are not under optimal control with 1.2mg after maintaining it for at least 6 weeks refer to speciality service. *Once substantive symptom improvement as per the SNAP-IV 18 and parent plus teacher report has been obtained; discontinue upwards titration and use as the daily target dose. Although infrequent, Health Canada and the FDA have warned about an increased risk of suicidal thinking in children and adolescents being treated with Strattera (Atomoxetine). Like other psychiatric medications, Strattera may increase thoughts of suicide or suicide attempts in children and teens. The primary care provider should document suicidal thoughts or attempts at each visit. The teens and the parents should be informed if they have suicidal thoughts or behaviors they should contact the primary care provider and the medication should be reassessed. Outcomes and side effects should be monitored regularly during treatment*. The following treatment process chart is suggested as a guideline. For treatment outcome evaluation, use the SNAP-IV (18 items) and the TeFA. For side effects assessment use the Kutcher Side Effects Scale for ADHD Medication (KSES-A) as illustrated in the Toolkit. See Follow up Table

Switching to Long Acting Forms…
When total daily dose is determined… Switch to long acting form Biphentin Concerta Nova-Methylphenidate ER-C Single daily morning dose Equivalent of initial Ritalin dose Long acting Methylphenidate Start at lowest dose; increase weekly Essential to evaluate twice/wk SNAP-IV Side Effects Scale Switching to Long Acting Forms When the total daily dose has been determined using the standard release form of methylphenidate, consider switching the medication to a long acting form, such as: Biphentin, Concerta, Novo-Methylphenidate ER-C (methylphenidate) given in a single daily morning dose at the approximate equivalent amount of the initial daily Ritalin dose. This strategy may be preferred to a multiple daily dosing of Ritalin standard release particularly if the teen is taking the medication at school. Alternatively; if all parties prefer, a long acting form of methylphenidate can be started at the lowest available dose and titrated upwards weekly until optimal symptoms improvement in the context of minimal side effects is achieved. If this approach is taken, it is essential that outcomes and side effects be evaluated at least twice each week using the SNAP – IV 18 and the Side Effects scale. Parents (or caregivers) can complete this form. Remember that the SNAP – IV 18 should be completed twice weekly by teachers as well. These forms should be brought to each appointment where the physician can review them. by photostock

Use PST Based Supportive Rapport
Switching to Atomoxetine If switching for reasons other than side effects Add Atomexetine until ADHD symptoms improve Then stop Methylphenidate Use PST Based Supportive Rapport Switching to Atomoxetine If it is decided to switch from Methylphenidate to Atomoxetine for other reasons than side effects, the recommended approach is to add Atomoxetine (as shown below) until ADHD symptoms improve and then stop Methylphenidate. * The PST based supportive rapport model should be used at every visit as a framework within which the interaction between the clinician and teenage patient can be structured. by Idea Go

Kutcher Side Effects Scale for ADHD Meds
Subjective Side Effects Never Somewhat Constant Anorexia 1 2 3 4 Weight Loss Abdominal Pain Dry Mouth Nausea Vomiting Fearful Emotional Lability Irritable Sadness Restlessness Headaches Trouble Sleeping Drowsiness Dry Eyes Suicidal Ideation Rash Acne Dyskinesia Tics Other Movements Sexual Effects Kutcher Side Effects Scale for ADHD Meds

Monitoring Treatment of Attention Deficit Hyper-Activity Disorder
Tool Base-line Day 1* Day 3* Wk 1 2 3 4 5 6 7 8 SNAP-IV 18 x CFA/TeFA WFIRS KSES-A Monitoring Treatment of ADHD Outcomes and side effects should be monitored regularly during treatment*. The following chart is suggested as a guideline. For treatment outcome evaluation use the KADS and the TeFA. For side effects assessment use the Short Chehil-Kutcher Side Effects Scale (sCKS) as illustrated on the next page. The PST based supportive rapport model should be used at every visit as a framework within which you can structure your interaction with your teenage patient. * For Stimulants Only

Duration of Treatment Maintain treatment for defined length of time to: Allow for further improvements in symptoms Allow for additional therapeutic interventions to occur (e.g. CBT or parent training) Decrease risk of relapse Decrease risk of a co-morbid mental disorder Duration of Treatment Once substantial improvement or recovery has occurred, the issue of duration of continued treatment arises. Maintaining treatment for a defined length of time is undertaken for the following reasons: To allow for further, perhaps longer to develop, improvements in symptoms and functioning to take place 2. To allow for additional or alternative therapeutic interventions to occur: for example the addition of cognitive behavioural therapy to a initial treatment with medication alone 3. To decrease the risk of relapse 4. To decrease the risk of developing a co-morbid mental disorder (for example: another anxiety disorder or major depressive episode) Currently, there exists insufficient substantive research to allow for good evidence driven guidelines for the duration of ongoing treatment following recovery from the index anxiety disorder freedigitalphotos.net renjith krishnan

Sustaining your goals It’s never too early to consider how you are going to sustain your improvements. Implementing a change in practice does not guarantee it will sustain long term. In order to continue to reap the benefits from your hard work you need to focus on how to ensure your change will ‘stick’. The risk of failing to sustain your changes is not just clinical, but can effect provider and staff satisfaction and future change efforts. As we talk about sustainability of your changes, think about how you as a team can sustain the changes you have made. Some strategies for holding the gains once initial improvements have been made (tested and implemented): 1. To work towards sustaining a change long term patients, staff and providers need to be clear what the benefits are in terms of patient care, workplace satisfaction, and personal practice. Using measurement to show the improvements will help to support the change. When each stakeholder can explain ‘what’s in it for me’ the change is more likely to sustain. 2. The permanence of the change should not depend on specific people, but should become embedded in the work processes. One of the ways to do this is to establish and document standard processes, so that even if there are staff changes everyone will know what the new process is and be able to follow it. Additionally, a plan for training new employees will help to ensure that the new responsibilities and new processes are understood and carried out correctly, and ensues continuity in practice over time. 3. Data collection continues so that the practice has information about whether the gains are being maintained. It may be that the data collection schedule can be reduced, with data collection occurring less frequently or with a smaller sample. The objective here is to monitor the new system, and guide improvements as they are tested and implemented. 4. One suggestion for embedding the change and making it permanent is to review job descriptions so that new personnel will know immediately what is involved in their responsibilities. Additionally, make sure that any documentations of policies and procedures reflect any change in process. 5. It is important to celebrate when an achievement has been reached, but also important to celebrate when that achievement has been sustained for a period of time. Keep focus and energy up by celebrating with your team your continued best practice and reminding yourselves of the good work you have done.

You can all work as one to sustain changes in practice and community!
As we talk about sustainability of your changes, think about how you as a team can sustain the changes you have made.

Next Learning Session Date
Please make a note of the date of the next learning session – evening session, same format to be expected. Thanks to the physician facilitators for their leadership in this module. Again, we at PSP are here to support you and coach you each step of the way.

Practice Support Program
For more information Practice Support Program West Broadway Vancouver, BC V6J 5A4 Tel:

PSP Child and Youth Mental Health

Similar presentations

Presentation on theme: "PSP Child and Youth Mental Health"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

PSP Child and Youth Mental Health

Similar presentations

Presentation on theme: "PSP Child and Youth Mental Health"— Presentation transcript:

Similar presentations

About project

Feedback