1. www.pspbc.ca PSP Child and Youth Mental Health Learning Session 3 © 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.

2. 2 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 Objectives

3. 3 A mind that is stretched by a new experience can never go back to its old dimensions. -Oliver Wendell Holmes, Jr.

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5. 5 Child & Adolescent Attention Deficit Hyper Activity Disorder (ADHD) dreamstimefree_1471290

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7. 7  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: Child & Adolescent ADHD

8. 8  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: Child & Adolescent ADHD www.freedigitalphotos.netwww.freedigitalphotos.net Upsidedown Vehicle by Bill Longshaw

9. 9  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 Typical School Report Card Notes

10. 10 3.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 ADHD Screening Question www.freedigitalphotos.netwww.freedigitalphotos.net Schoolboy Does Exam Papers

11. 11 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)? www.freedigitalphotos.netwww.freedigitalphotos.net Question Or Doubt by Jeroen van Oostrom

12. 12 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)? www.freedigitalphotos.netwww.freedigitalphotos.net Family by Master isolated images

13. 13 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) 1.A previous diagnosis of ADHD 2.Family history of ADHD 3.Family history of mental disorders (affective, anxiety, tics or conduct disorder) 4.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) 1.School failure or learning difficulties 2.Socially isolated from peers or behavioural problems at home and at school (including gang activity & legal problems) – accident prone. 3.Bullying (victim and/or perpetrator)

14. 14  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 Freedigitalphotos Africa 31513qkoh8f72ro Approx. 65% of children with ADHD still meet diagnostic criteria during adolescence

15. 15 3 Sub-categories Predominantly Inattentive 1. Predominantly Inattentive Predominantly Hyperactive-Impulsive 2. Predominantly Hyperactive-Impulsive Combined Inattentive/Hyperactive 3. Combined Inattentive/Hyperactive Screening & Diagnosis of ADHD

16. 16  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 3 – 5 years of age dreamstimefree_113773

17. 17  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 6-12 years of age www.freedigitalphotos.netwww.freedigitalphotos.net Girl With Bunny by Teeratas

18. 18  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 6-12 years of age

19. 19  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 13 – 19 years of age www.freedigitalphotos.netwww.freedigitalphotos.net Glamour by federico stevanin

20. 20  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 13 – 19 years of age

21. 21 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 Q’s stockxchng ID 1049528

22. 22  Assessment of ADHD › Four 15 minute office visits  Treatment is NOT an emergency › Take your time › Ensure diagnosis is correct www.freedigitalphotos.netwww.freedigitalphotos.net Break by Salvatore Vuono

23. 23  A norm-referenced checklist  DSM-IV criteria for ADHD SNAP-IV Teacher and Parent 18-item Rating Scale Assessment Tool

24. 24 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 Assessment Tool SNAP-IV Teacher and Parent 18-item Rating Scale

25. 25  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 SNAP-IV Teacher and Parent 18-item Rating Scale Assessment Tool

26. 26  What to do if a SNAP-IV score of 18 or higher: SNAP-IV Teacher and Parent 18-item Rating Scale Assessment Tool

27. 27 Monitoring  CGI  TeFA / CFA  TASR-A  SNAP-IV Interventions (these do not replace medications or psychotherapies)  PST  WRP Monitoring and Intervention Tools: ADHD

28. 28 Children Visit 1 Visit 2 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 1 - 2 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. Consider risk factors Apply screening tool Complete CFA Complete SNAP-IV SNAP-IV 18 item CFA Use PST and WRP 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”. 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. 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.

29. 29 Visit 3 SNAP-IV 18 CFA Use PST and WRP 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** 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. www.freedigitalphotos.netwww.freedigitalphotos.net Download Two Girls On A Swing by Naypong Children

30. 30 Visit 1 Visit 2 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 1 - 2 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. Consider risk factors Apply screening tool TeFA SNAP-IV SNAP-IV 18 item TeFA Use PST and WRP 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”. 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. 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. Youth

31. 31 Visit 3 SNAP-IV 18 TeFA Use PST and WRP 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. 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. freedigitalphotos Sujin Jetkasettakorn Youth

32. 32  Approx. 30 – 50% of people with ADHD have other psychiatric disorders › Oppositional Defiant Disorder (ODD) › Conduct Disorder (CD) › Learning Disorder Co-morbidity in ADHD

33. 33  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 www.freedigitalphotos.netwww.freedigitalphotos.net by Salvatore Vuono

34. 34 Pharmacological Treatment of Child & Adolescent ADHD

35. 35 Baseline Measurement  Complete blood count  Complete blood count (CBC)  Height; Weight; Blood Pressure; Pulse Rate  SNAP-IV 18 Items Rating Scale  WFIRS-P  WFIRS-P (Weiss Functional Impairment Rating Scale- Parent Report)  CFA  CFA (Child Functional Assessment)  KSES-A  KSES-A (Kutcher Side Effects Scale for ADHD Meds)  Family history of heart disease CBC Ht Wt BP Pulse Ht Wt BP Pulse SNAP-IV 18 KSES-A History www.freedigitalphotos.netwww.freedigitalphotos.net by Mrpuen

36. 36  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 www. Freedigitalphotos by Danilo Rizzuti

37. 37 Stimulants & Non-Stimulants Available in two different forms Highly effective Available for decades Well studied Safe prescribed to healthy patients under medical supervision Stimulants Non-Stimulants For youth… 1.Not responding well to stimulant medications 2.At risk for substance abuse 3.With other conditions with ADHD 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.

38. 38  Tricyclic antidepressants (not recommended) >Imipramine or Desipramine  Bupropion >Wellbutrin  Clonidine Reserve these medications for specialty mental health services Additional ADHD Medications www.freedigitalphotos.netwww.freedigitalphotos.net by Wishedauan

39. 39  Evaluating response to Methylphenidate >3-day baseline assessment o SNAP-IV 18  Alternate every 3 days for 12 days: >Dose of methylphenidate (standard release) o 5 mg/BID or 10 mg/BID depending on weight >Dose of placebo  Daily measurement >Symptoms (SNAP-IV 18) >Side Effects (KSES-A) 39 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 Medication5 - 10mg /bid Placebo Medication5 - 10mg /bid

40. 40  Concerning with alcohol/drug abuse >Careful evaluation and monitoring >Avoiding drug diversion >Sustained-release preparations >Non-stimulants >Consider using Atomoxetine >Studying for exams www.freedigitalphotos.netwww.freedigitalphotos.net by Africa

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43. 43 NOTE: If symptoms are not under optimal control with 1.2mg after maintaining it for at least 6 weeks refer to speciality service.

44. 44  When total daily dose is determined… >Switch to long acting form o Biphentin o Concerta o 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 o SNAP-IV o Side Effects Scale www.freedigitalphotoswww.freedigitalphotos by photostock Switching to Long Acting Forms…

45. 45  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 www.freedigitalphotos.netwww.freedigitalphotos.net by Idea Go

46. 46 Kutcher Side Effects Scale for ADHD Meds Subjective Side EffectsNeverSomewhatConstant Anorexia01234 Weight Loss01234 Abdominal Pain01234 Dry Mouth01234 Nausea01234 Vomiting01234 Fearful01234 Emotional Lability01234 Irritable01234 Sadness01234 Restlessness01234 Headaches01234 Trouble Sleeping01234 Drowsiness01234 Dry Eyes01234 Suicidal Ideation01234 Rash01234 Acne01234 Dyskinesia01234 Tics01234 Other Movements01234 Sexual Effects01234

47. 47 Tool Bas e- line Day 1* Day 3* Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 SNAP-IV 18 xxxxxxxx CFA/TeFA WFIRS xxxxx KSES-Axxxxxxxx Monitoring Treatment of Attention Deficit Hyper-Activity Disorder Monitoring Treatment of Attention Deficit Hyper-Activity Disorder * For Stimulants Only

48. 48 1.Allow for further improvements in symptoms 2.Allow for additional therapeutic interventions to occur (e.g. CBT or parent training) 3.Decrease risk of relapse 4.Decrease risk of a co-morbid mental disorder Maintain treatment for defined length of time to: freedigitalphotos.net renjith krishnan Duration of Treatment

49. 49 Sustaining Your Gains

50. 50 You can all work as one to sustain changes in practice and community!

51. 51 Thank you!