CLINICAL PRACTICE GUIDELINES FOR THE ASSESSMENT AND TREATMENT OF

CHILDREN WITH

COMPLEX ADHD

Matthew Hickling, CPNP-PC, MSN, BSN, RN

Developmental Pediatrics – Community Care Physicians, PC

DISCLOSURES

• I have no financial or professional disclosures

• There will be no discussion of non-FDA approved drugs.

ADHD TODAY

DID YOU KNOW…

LEARNING OBJECTIVES

• To review current co-morbidities in the diagnosis and treatment of Attention-Deficit/Hyperactivity Disorder (ADHD)

• To provide a brief understanding of what treatment for complex ADHD entails

• Integrate knowledge of the diagnosisand management of ADHD in childrenwith comorbid disorders into theirprimary care patient managementplans

WHAT IS THE MOST COMMON COMORBIDITY WITH ADHD

Choice 1 – Anxiety Disorder

Choice 2 – Autism

Choice 3 – Oppositional Defiant Disorder

Choice 4 – Learning Disability

Choice 5 – Tic disorders

AAP AND SDBP

• American Academy of Pediatrics (AAP) =

• Population for diagnosis = All children ages 4-17 presenting to primary care (usually for the first time) with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity

• Society for Developmental and Behavioral Pediatrics (SDBP) guideline complements AAP and guides all professionals managing care of children and adolescents with complex ADHD

WHAT COMPLICATES THE EVALUATION AND TREATMENTS FOR A PATIENT TO BE CONSIDERED

“COMPLEX ADHD?”

Choice 1 – Presenting at an unusually early (<4

years) or late (>12years) age

Choice 2 – Having a coexisting condition

(medical, psychiatric, or developmental/learning)

Choice 3 – Moderate to severe impact of symptoms

on daily functioning and inadequate response to

treatment

Choice 4 – Primary care provider being uncertain

about the ADHD diagnosisChoice 5 – All the above

< 4 yearsPresentation at age > 12 years

Age

Complex ADHD

Developmental/learning issuesMedical diagnosesPsychiatric diagnoses

Co-occurring conditions

Moderate to SevereFunctional Impairment

Diagnostic uncertainty

Inadequate response to treatment

PRIMARY -• Focus on functional impairment to

improve long term outcome• Focus on psychosocial

treatment as the foundation for treatment of complex ADHD

Others include:

• Shared decision making and clinical judgement

• Interprofessional care

• Psychological Testing/Mental Health Assess

• Multimodal treatment

• Evidence Based Psychosocial Interventions

• Treatment for Coexisting Conditions

• Life Course Perspective.

SDBP CURRENT PRACTICE MODEL

CASES FOR REVIEW

CASE 1

• Male – 3 years / 6 months• Referral – rule out ASD

• Hx –

• 35 wks gestation / in utero cocaine exposure & several psychotropic medications during pregnancy.

• Unsure of alcohol or other illicit drugs

• Sx of drug withdrawal first few weeks after birth

• Dc’d directly into Foster Care. Living with Grandmother since 12 months of age.

• Hx (continued) –

• EI evaluation led to ST around 1yo. Transitioned to CPSE – placed in SE. Continues with ST and 12-month programming.

• On-going delays in language skills – speaking in 3–5-word sentences. Points for wants/needs.

• Enjoys playing with cars, puzzles, blocks. Not engaging in imaginative play and has avoided playing with others. Some improvement since starting school.

• Behaviorally – high activity level and increased impulsivity. Led to safety concerns. Difficulties in emotional regulation. Inflexible and difficulty with transition.

Complete medical & developmental history and physical examination

Evaluation of data from multiple settings, including any prior evaluations

Psychological and/or developmental assessment including assessment of symptom severity, functional impairment, and cognitive/developmental level

Verification of any prior diagnoses and assessment for coexisting conditions

SPECIALIST APPROACHComprehensive

Evaluation

ACADEMICS/ EARLY LEARNING

Academic underachievement/ Early LearningCo-occurring learning disabilities

Functional Impairment

SOCIAL INTERACTION Parent-child interaction problemsDifficult peer relationships & other social issues

SELF-CONCEPT Low self-esteem

ACTIVITIES Suboptimal community participationIncreased risk of accidents (injuries, driving)

CASE 1 (CONT)

Exam –

Delays in multiple domains of development

Free play – initially hesitant then cautiously engages with toys

Quiet and avoids eye contact

Demonstrates functional play – no complex imaginative play

Begins to run and climb and furniture

Nonverbal cognitive skills between 18-21 months

Drawing skills – 15 months

Initially – no speaking. Once comfortable – single words and short phrases. Mix of words and jargon.

Frustration when not understood

Evidence of diminished attention span, increased impulsivity, and difficulty with emotional regulation.

Some difficulty with transition

WHAT DO YOU THINK IS THE DIAGNOSIS FOR THIS CHILD?

Choice 1 – Anxiety

Choice 2 – ADHD

Choice 3 – Autism

Choice 4 – Disruptive and Oppositional Behavior

Choice 5 – Multiple Co-Morbidities

TRAUMA

MANAGEMENT

• Behavioral interventions are the first line of treatment• Families should look for a therapist who

focuses on training parents – Behavioral Parent Training (BPT)

• Project TEACH Provider Database• School based interventions (daily report

cards, classroom token economy, 504/IEP, Functional Behavioral Analysis and Behavior Intervention Plans.

• Peer focused social skills (Behavioral Peer Intervention)

• Trauma focused interventions when indicated• When behavioral treatment is not available,

clinicians must weigh risks and benefits of starting medication vs. harm of delaying treatment

PRESCHOOL-AGED CHILDREN (3-6 YEARS)

Barbaresi WJ, Campbell L, Diekroger EA, et al. The Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder: Process of Care Algorithms. J Dev Behav Pediatr. 2020;41 Suppl 2S:S58-S74. doi:10.1097/DBP.0000000000000781

CASE 2

• Jacob is an active 7-year-old recently diagnosed with ADHD

• Referred to office for “ADHD and something more.”

• Attempted methylphenidate 10mg daily one month ago. Administered before 8am daily.

• Limited appetite during the day. No difficulty with insomnia.

• Mom notes impulsivity worse – getting in trouble in school for “meltdowns.”

• He has yelled, fought, and damaged classroom property.

• Mom states he will come into her room at night because he is worried there is a “bad man” in the house

• Meds stopped 2 days ago and there has been a decrease in anger.

CASE 2 (CONT.)

• We did a SCARED and re-did hisVanderbilt scale.

• Vanderbilt positive for H/I symptoms,

• SCARED positive for anxiety disorder, separation anxiety, and social anxiety disorder

• Confirmed his prenatal history was negative for maternal illness, maternal substance use and confirmed he had no perinatal difficulties.

• Development is normal

• Academic achievement has been good until this academic year

DIAGNOSTIC ASSESSMENT

• Determine that DSM-5 criteria have been met

• Document symptoms and impairment in more than 2 major settings

• Rule out any other alternative cause of symptoms/impairment

• Screen for comorbid conditions, including

• emotional/behavioral conditions (e.g., anxiety, depression, ODD, conduct disorder, substance use)

• developmental conditions (e.g., autism spectrum disorder, learning disorders, language disorders)

• physical conditions (e.g., tics, OSA)

ACADEMICS Academic underachievementCo-occurring learning disabilities

Functional Impairment

SOCIAL INTERACTION Parent-child interaction problemsDifficult peer relationships & other social issues

SELF-CONCEPT Low self-esteem

ACTIVITIES Suboptimal community participationIncreased risk of accidents (injuries, driving)

WHAT DO YOU THINK IS THE CO-MORBID DIAGNOSIS FOR THIS CHILD?

Choice 1 – Anxiety

Choice 2 – Autism

Choice 3 – Oppositional Defiant Disorder

ANXIETY

15% to 35% of kids with ADHD have a coexisting anxiety disorder.

Commonly present with somatic complaints- esp H/A and SA

Many end up with OCD behaviors

Crying, irritability and anger may be misunderstood as oppositionality or defiance

So, which one is causing more problems and more impairment?

Is anxiety improved and now less impairing than ADHD?

ADHD and Coexisting Anxiety Child with ADHD and Anxiety

• Begin Cognitive Behavioral Therapy (CBT)

• Monitor response

Continue CBT and consider modification (e.g., more parent

involvement, more in vivo exposures)

• Initiate 8 week trial of SSRI • Continue CBT• Monitor response

• Continue to adapt CBT• Consider medication change • Monitor and modify treatment

Is anxiety more impairing than ADHD?

To Behavioral/Educational Treatment of Complex

ADHD Algorithm

To Behavioral/Educational Treatment of Complex

ADHD Algorithm

To Behavioral/Educational Treatment of Complex

ADHD Algorithm

Is anxiety improved and now less impairing than ADHD?

Is anxiety improved and now less impairing than ADHD?

To Behavioral/Educational Treatment of Complex

ADHD Algorithm

NoYes

Yes

No

Yes

No

NoYes

Barbaresi WJ, Campbell L, Diekroger EA, et al. The Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder: Process of Care Algorithms. J Dev Behav Pediatr. 2020;41 Suppl 2S:S58-S74. doi:10.1097/DBP.0000000000000781

MANAGEMENT

• Consider what might be the Primary condition “driving the bus.”• Cognitive Behavioral Therapy

Re-evaluation: IF symptoms have improved – Continue with Behavioral/Educational treatment – CBT,

classroom, etc.IF symptoms have NOT improved –

- Continue CBT and consider modifications (increasing parental involvement)Re-evaluation:

IF symptoms have improved – Continue with Behavioral/Educational treatment – CBT, classroom, etc.

IF symptoms have NOT improved –- Initiate 8-week trial of SSRI- Continue CBT and consider modifications (increasing parental involvement)- Monitor response

COMMUNITY RESOURCES

County Mental Health Clinics

Non-for-Profit Organizations• Northern Rivers• BHSN• St. Catherine’s

School Counseling services

Private Therapists

Community Care Physicians, PC –

Integrated Behavioral Health Team

Project TEACH

PCP APPROACH

Refer to a specialist with appropriate training or expertise

Screen broadly for co-existing conditions and functional impairment

Consider who may benefit from a comprehensive assessment

ADVOCACY AND FUTURE RESEARCH

• The guideline highlights the need for advocacy to address the many systemic barriers to delivering optimal care for complex ADHD.

• These include: • Financial barriers • Inadequate expertise and recognizing complexity

• Limited number of subspecialists • Limited resources within the education system T

•Health care systems to defer financial and treatment responsibility

SUMMARY

• ADHD = Chronic Condition

• Start with psychoeducation

• Create a partnership with the family

• Develop a management plan with specific targeted goals

• If possible, include the teachers

• Plan for ongoing monitoring and anticipation of developmental changes & transitions

• Communication and coordination of care among all professionals involved in the treatment and management of children and adolescents with complex ADHD is of utmost importance.

REFERENCES

• Barbaresi WJ Campbell L, et al. Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder. J Dev Behav Pediatr 2020; 41:S1-S23

• Barbaresi WJ Campbell L, et al. Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder: Process of Care Algorithms. J Dev Behav Pediatr. 2020b; 41: S1-17.

• Wolraich ML, Chan E, Froehlich T, et al.ADHD Diagnosis and Treatment Guidelines:A Historical Perspective. Pediatrics. 2019;144(4): e20191682

• Wolraich ML, Hagan JF, Allan C, et al. SUBCOMMITTEE ON CHILDREN AND ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVE DISODER. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrcis. 2019; 144(4):e20192528

• SDBP Complex ADHD Guideline: Executive Summary. Zand D, Diekroger E, Koolwijk I, Noaln R, Augustyn M, Yang J, Buttross S, Mehlenbeck R, Froelich T.

• SDBP Complex ADHD Guideline: Talking Points for Clinicians and Health Care Providers. Ledesma M, Moore T, Nolan R, Lopez FA

• SPECIAL THANKS:

• Dawn Garzon Maaks – helped with advising on materials

• Dr. Ledesma and SDBP for information and helps with slides

• Dr. Anthony Malone, Dr. Chaudauri, Erin Larrabee, and Maude Kaye