1. Practice Key Driver Diagram

2. Chapter Quality Network ADHD Project Teresa Hargrave MD ADHD Expert Putting ADHD Evidence Into Practice through QI

3. Teresa Hargrave MD 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 3

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

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

6.  Phone Consult Line 1-855-CAP-PC72 (1-855-227-7272)  Website: www.cappcny.orgwww.cappcny.org  Face-to-Face (one time only)  Evening Webinars  “Fireside Webcasts”  REACH training NYS OMH Project TEACH: CAP-PC

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

8. The guidelines acknowledge the challenges of caring for children with ADHD and the challenges posed by their recommendations. Barriers and Frustrations

9.  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

10. That’s why we’re here.

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

12. 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

14. Key Action Statement 1: 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).

15. Mental Health Screening Tools CAP-PC/Project TEACH website: www.cappcny.org

16. Key Action Statement 2: DSM-5, including Differential Diagnosis To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders criteria have been met (including documentation of impairment in more than 1 major setting ); information should be obtained primarily from reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause (quality of evidence B/strong recommendation).

18. 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

19. Vanderbilt Assessments

20.  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

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

22. Differential Diagnoses MedicalPsychologicalEducational Sleep disorders Seizures Tourette’s/Tics Thyroid Disorders Traumatic Brain Injury Medication Vision or Hearing Issues Anxiety Depression ODD/CD/IED OCD ASD SUD Thought Disorders/ Psychosis PTSD Intellectual Disability LD/Dyslexia Processing Issues Speech/Language Working Memory

23. Sometimes the Best Diagnosis is No Diagnosis  Immaturity  80th percentile hyperactivity, impulsivity  Gifted, under-challenged  Behavior problems not related to a psychological diagnosis  Unhealthy classroom environment  Chaotic home environment (e.g., foster care)  Victim of bullying  Odd (not ODD)  Temperamental differences

24. Key Action Statement 3: Co-Morbid/Co- Occurring Conditions In the evaluation of a child for ADHD, the primary care clinician should include assess ment for other conditions that might coexist with ADHD, including emotional or behavioral (eg, anxiety, depressive, oppositional defiant & conduct disorders), developmental (eg, learning and language disorders or other neurodevelopmental disorders) & physical (eg, tics, sleep apnea) conditions (quality of evidence B/strong recommendation).

25. Co-Morbid or Co-Occuring Conditions MedicalPsychologicalEducational Sleep disorders Tourette’s/Tics Pain Anxiety Depression/Mood Disorder ODD/CD OCD ASD Intellectual Disability LD/Dyslexia Processing Issues Speech/Language Working Memory

27. Key Action Statement 4: Management Chronic Care & Medical Home Models The primary care clinician should recognize ADHD as a chronic condition and, therefore, consider children and adolescents with ADHD as children and youth with special health care needs. Management of children and youth with special health care needs should follow the principles of the chronic care model and the medical home (quality of evidence B/strong recommendation).

28. 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:

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. Preschool ADHD Treatment Study PATS

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

32. 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

33. Behavior Therapy  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/teachers 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.

34. HHS Agency for Healthcare Research and Quality 2011 Report  Triple P  PCIT  Incredible Years  New Forest Parenting Programme

35. IY Parenting Pyramid

36. William Pelham, Jr., PhD, Chair of Psychology at FIU It can be difficult to refer kids to behavioral therapy with qualified mental health professionals...all (physicians) have in their tool kit is medication.

37. 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).

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).

40. 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.

41. ADHD Med Hierarchy  First line: A stimulant  Second line: A stimulant from the other class of stimulants  Third line: atomoxetine  Fourth line: guanfacine or clonidine  Fifth line: the other fourth line

42. Choosing Where to Start:

46. Choosing Where to Start  FH : Has something worked well for someone else in the family?  Can your patient swallow pills whole?  What will insurance pay for?

47. When in doubt: Call CAP-PC /Project TEACH for a Phone Consult 1-855-227-7272

49. 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).

50.  Start low, go as quickly as makes sense  End Points: desired response, minimal side effects  Weight no longer the determining factor Dose Titration: Variation in Individual Response

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. 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)

54. Initiating a Stimulant Trial “The school environment, program, or placement is a part of any treatment plan. (No quality of evidence sited)”  Frequent input required from teachers and parents  Use Vanderbilt to get objective information  Typically, use short Vanderbilt (focus on ADHD symptoms)  If co-morbidities, use long Vanderbilt (adds externalizing/internalizing questions) Nikles et al. Pediatrics; 2006, 117, 2040-2046

55. Initiating a Stimulant Trial, con’t  Rapid titration recommended: as often as weekly  Regular assessment for medication side effects  Target optimal dose to defined end-points: 25% drop in Total Symptom Score (Vanderbilt) Nikles et al. Pediatrics; 2006, 117, 2040-2046

56. Stimulant Monitoring Sandwich Vanderbilt, Ht, Wt, P, BP 1-2 Weeks Vanderbilt, Ht, Wt, P, BP

57. Nonstimulant Monitoring Sandwich Vanderbilt, Ht, Wt, P, BP 3-4 Weeks Vanderbilt, Ht, Wt, P, BP

59. Objectives: 1) Maintain symptom reduction 2) Oversee gradual decrease in impairment 3) Monitor for long-term side effects Ultimate goal: NO IMPAIRMENTS Medication Management: Maintenance

60.  Once stable, quarterly visits for remainder of school year  Subsequent years: re-assess 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

61. ADHD NOS  Behavioral interventions might help families of children with hyperactive/impulsive behaviors that do not meet full diagnostic criteria for ADHD. (No evidence guideline)

62. When nothing seems to work:

63. Think Imposter

64. Think Comorbidity

65. Face-to-Face Call CAPPC: 1-855-227-7272

66. 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.”

67. That’s why we’re here!