1. Diagnosis and Treatment of ADHD
Amy Williams, DNP, APRN, CPNP-PC
Assistant Professor
MUSC College of Nursing

2. Learning Objectives Review the DSM 5 criteria for ADHD
Discuss differential diagnoses
Identify some of the common co-morbidities
Describe the diagnostic process
Discuss various treatment approaches including non pharmacological approaches

3. Differential Diagnosis
Mood Disorder
Anxiety Disorder
Learning Disorder
Mental Retardation
ODD/Conduct Disorder
Developmental Disorder
Parenting
AACAP, 2007

4. Differential Diagnosis
Seizure Disorders
Chronic Otitis Media
Hyperthyroidism
Sleep Apnea
Head Injury or trauma
Toxic Exposure (lead)
Hearing and vision screens

5. Epidemiology Most commonly diagnosed behavioral disorder of childhood
Estimates range from approximately 5% to 9.5%
Variability by gender (boys are more than twice as likely to be diagnosed)
Girls typically show less hyperactivity, fewer conduct problems, & less externalizing behavior and are often diagnosed at older ages
AACAP, 2007

6. Diagnostic Tools Scales: Preschool ADHD Rating Scales
Vanderbilt Rating Scales (free and downloadable from brightfutures.org)
Conners-3 Rating Scale
Direct Testing Options:
QB Test
Conners CPT

7. DSM-V Diagnostic Criteria (Inattention)
Makes careless mistakes/poor attention to detail
Difficulty sustaining attention in tasks/play
Does not seem to listen when spoken to directly
Difficulty following instructions
Difficulty organizing tasks/activities
Avoids tasks requiring sustained mental effort
Loses items necessary for tasks/activities
Easily distracted by extraneous stimuli
Often forgetful in daily activities DSM 5, 2013

8. DSM-V Diagnostic Criteria (Hyperactive/Impulsive)
Fidgets leaves seat
Runs or climbs excessively (or restlessness)
Difficulty engaging in leisure activities quietly
Busy!
Talks excessively to peers
Blurts out answers before question is completed
Difficulty waiting turn!
Interrupts others DSM

9. DSM-V Criteria 6 of 9 symptoms in either or both categories
Code as: Inattentive; Hyperactive-Impulsive; or Combined Type
Persisting for at least 6 months
Some symptoms present before 7 y/o (4 yrs. AAP)
Impairment in 2 or more settings
Social/academic/occupational impairment
(DSM 2013)

10. Subtypes of ADHD Combined Presentation
Predominately Inattention Presentation
Predominately Hyperactive/Impulsive Presentation

11. How to Diagnose
Clinical Interview + Rating Scales, Direct Observation- caregivers often report concerns!
Symptoms present before age 12, occur in at least two settings, and are not better explained by another diagnosis
Behavior has to occur in 2 or more settings – importance of collateral information from teachers/daycare providers, etc.

12. Why More ADHD diagnosis ?
Improved recognition?
Increase in prevalence?
Increased scholastic demands?
Technology?
Parenting ?
Culture ?

13. Executive Functioning
Most children with ADHD have impairments in executive functioning, including:
Response inhibition
Working memory/organization
Difficulties with planning

14. Reviewing the Diagnosis
There is no one single test to identify ADHD
1. Conners
2. Vanderbilt ADHD rating scale
3. SCARED CHILD (co- morbid anxiety)
4. Academic Performance Rating Scale
5. Child behavior checklist
6. PHQ –A( rule out depression)
Diagnosis must be multi-factorial and behaviors in more than 1 setting
AACAP, 2007

15. Getting to a Diagnosis
Review of psychiatric systems (attention, hyperactivity/impulsivity, oppositional & conduct problems , mood, anxiety, history of trauma,
tics, substance abuse)
2. Medical, psychiatric, & developmental history
Educational history ( grades, teachers reports)
3. Family & social history
4. Psychological/IQ testing
AACAP, 2007

16. Diagnosis Other interviews: Patient
Primary Caregivers (parents, and family)
Teachers
School Counselors
Coaches
Children with ADHD can often function well in certain settings with no signs of symptoms when they are interested and can maintain total focus (e.g., playing video games, focused activities )

17. Treatment
Medication
Behavioral Therapy – improvement most significant with both medication & therapy
Cognitive/Behavioral Therapy- self esteem
Parent Management Training- PCIT, Triple P, Special time
Social Skills Training- need practice and role models
Educational Support
504 Plan
Individual Educational Plan (IEP) AACAP, 2007

18. Stimulants : Mechanism of Action
Enhancement of dopamine and norepinephrine in certain brain regions (basal ganglia, prefrontal cortex, hypothalamus)
Increases norepinephrine and dopamine by blocking the reuptake and facilitating their release
Stahl, 2019

19. Stimulants : Dosage & Administration
Routine PE prior to initiation of stimulants; Vitals each visit
Long-acting treatments can be started initially
Concerta is also recommended as good long acting first agent
Start at lowest dose and titrate slowly
Must educate parents that all behavior won’t necessarily change immediately
Stahl, 2019

20. Methylphenidate Methylphenidate Ritalin (age 6 and above ) Metadate
Concerta
Quilliachew
Daytrana patch
Contempla

21. Amphetamine-D,L Adderall (ages 3 and older ) Adderall XR Evekeo
Adzenys
Mydayis (newer- marketed for older children and teens) 12 and above)
Vyvanse (lisdexamphetamine dimesylate)
Stahl, 2019

22. Stimulants: Side Effects & Contraindications
Side Effects: Nausea, headache, early insomnia, decreased appetite; tics, anxiety, HTN/tachycardia
Stahl, 2019
Contraindications: cardiovascular disease, glaucoma, hyperthyroidism, tics/Tourette’s ,SUD, or psychosis

23. Guidelines
1. Certain heart conditions in children may be difficult to detect, the AAP, AACAP, and AHA recommend it is important to carefully assess children for possible heart conditions
2. Obtaining a patient and family health history and doing a physical exam focused on cardiovascular disease risk factors is recommended
3. Getting an ECG is a recommendation. This is at the providers discretion AACAP,2007

24. Stimulants: Pros & Cons
Highly effective
Long history of use
Improved educational and social functioning (self esteem)
Cons:
Limited duration of action –the PM meltdown!
Side effects -Nausea, headache, insomnia, decreased appetite, tics anxiety, tachycardia, psychosis
Difficulty initiating and maintaining sleep
Document assessment for side effects at each visit

25. Stimulants Prior to treatment
Height, weight, Blood Pressure & Heart Rate
12 lead EKG
Family history of sudden cardiac death and/or personal or family history of syncope, chest pain, shortness of breath, or exercise intolerance warrants an ECG and pediatric cardiology referral for an echo
During Treatment
Height & weight ( I do at each visit )
Monitor BP and pulse at each visit AACAP,2007

26. Alpha 2 Adrenergic Agonists
Clonidine binds to the three subtypes of alpha (2) -receptors, A, B and C, whereas guanfacine binds more selectively to post-synaptic alpha (2A) receptors, which enhances prefrontal function
Stimulation of the post-synaptic alpha-2A receptors is thought to strengthen working memory, reduce distraction, improve attention, improve behavioral and impulse control
Sadock, 2015

27. -2 Agonists
Useful for hyperactivity & impulsivity, insomnia, treatment emergent tics, & ODD
Clonidine (0.1mg – 0.3 mg/)HS & Guanfacine (1mg– 4 mg)
Routine PE/VS prior to initiation Contraindications: CAD, impaired liver/renal function
Side Effects: Rebound changes in BP /tachycardia, sedation, dizziness, constipation, fatigue -
Dosage: Start with HS- educate to not stop suddenly
Monitor BP and pulse but ECG not necessary unless CAD hx
Stahl, 2019

28. Intuniv
Guanfacine ER
Nonscheduled, alpha-2A receptor agonist indicated for ADHD
Children and adolescents, ages 5 – 17 years
Dosages of 1, 2, 3, and 4 mg once daily
Use for ODD and impulsivity off label
(some Medicaid plans will not reimburse for long acting)

29. α-2 Agonists: Cons: Pros:
Side Effects: Rebound HTN/tachycardia, sedation, dizziness, constipation, H/A, fatigue, sudden death in combination with stimulants
Contraindications: CAD, impaired liver/renal function
Pros:
Moderately effective (residual hyperactivity & impulsivity, insomnia, treatment emergent tics, & aggression)

30. Combination Tx
Stimulant + α-2 Agonist : try to use only one agent if possible
FDA does not limit use
AACAP recommends against routine ECGs unless family history of CAD
Include family health history for CAD

31. Atomoxetine HCl (Strattera):
Norepinephrine reuptake inhibitor; acts at presynaptic neuron;
Dosing 10 mg- 80 mg po daily
Some children report improvement while others report no change
Watch for any behavioral change –mood, irritability
24-hour duration of action with once-daily dosing in am
Not contraindicated in patients with tics and anxiety
Stahl, 2019

32. Questions ?

33. References
American Academy of Child and Adolescent Psychiatry (2007) Practice parameters for the assessment and treatment of children and adolescents with Attention Deficit/Hyperactivity Disorder Retrieved fromhttps://
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s Synopsis of psychiatry: behavioral sciences/clinical psychiatry (11th ed.). Philadelphia: Lippincott Williams & Wilkins.
Stahl, S. (2019). Essential psychopharmacology prescribers guide: children and adolescents (1st ed). New York: Cambridge University Press
Dulcan, M. (2015). Child and adolescent psychiatry (2nd ed.). Arlington, VA: America Psychiatric Association Publishing.