primary care management of adhd bradley steinfeld, phd assistant director of professional services...
TRANSCRIPT
PRIMARY CARE MANAGEMENT OF ADHD
Bradley Steinfeld, PhD
Assistant Director of Professional Services
Group Health Behavioral Health Services
OBJECTIVES
• Overview of prevalence and characteristics of childhood and adult ADHD
• Role of Primary Care Provider in assessment and treatment of ADHD
• Tools to assist Primary Care Provider in diagnosis and treatment of ADHD
• Group Health Cooperative Adult and Childhood Clinical Guidelines, 2011
• American Academy of Pediatrics 2011 Guidelines on Childhood ADHD
• ACAP ADHD Took Kit 2011
• NICE Adult and Childhood ADHD Guidelines, 2008.
Primary Reference Resources
Role of Specialties
• Family practice providers who have an interest and adequate training can diagnose and treat children with ADHD
• Pediatric providers should have the skills to diagnose and treat children with ADHD
• Behavioral Health Services (BHS) disciplines –should have the skills to diagnose and treat the children with ADHD who are referred to them
• Consider the involvement of mental health professionals for diagnosis and treatment of ADHD for children under the age of 5 years
A report from the Center of Disease Control and Prevention (2010) provides the following information about prevalence:
• In 2007, the estimated prevalence of parent-reported ADHD among children aged 4-17 years was 9.5%
• ADHD was more than twice as common among boys as girls (13.2% vs 5.6%)
• 30-40% of children with ADHD continue to have ADHD as adults
PREVALANCE OF ADHD
Prevalence of Co morbidities:
• Learning disabilities 25%• Social skills deficits: 50%• Oppositional defiant disorder: 60%• Anxiety: 20%• Depression: 30%
DSM-IV ADHD Criteria
Presence of either of the following (1 and/or 2)
1. Six (or more) of the following symptoms on inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
• Often fails to give close attention to details or make careless mistakes in schoolwork, work or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen when spoken to directly
DSM-IV (continued)
• Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• Often has difficulty organizing tasks and activities• Often avoids, dislikes or is reluctant to engage in tasks that require
sustained mental effort (such as schoolwork or homework)• Often loses things necessary for tasks or activities (e.g. toys, school
assignments, pencils, books or tools)• Is often easily distracted by extraneous stimuli• Is often forgetful in daily activities
Additional DSM-IV Criteria
2. Hyperactivity/Impulsivity (six or more of the following)
• Often fidgets with hands or feet or squirms in seat• Often leaves seat in classroom or in other situations in which remained
seated is expected• Often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to subjected feelings of restlessness)
• Often has difficulty playing or engaging in leisure activities quietly• Is often “on the go” or often acts as if “driven by a motor”• Often talks excessively
Additional DSM-IV Criteria (continued)
Impulsitivity
• Often blurts out answers before questions have been completed• Often has difficulty waiting turn• Often interrupts or intrudes on others (e.g. butts into converstaions
or games)
DSM-IV Classification of ADHD
Classifications:
Combined type ADHD• If criteria for both inattention and hyperactivity-impulsivity are met for
the past 6 months
Predominantly inattentive type ADHD• If criteria for inattention but not hyperactivity-impulsivity are met for
the past 6 months
Predominantly hyperactive-impulse type ADHD• If criteria for hyperactivity-impulsivity but not inattention are met for
the past 6 months
Keys to Assessment
• Presence of ADHD related symptoms as reported by parents and teacher (e.g. inattention, hyperactivity, impulsivity) in multiple settings
• Symptoms significantly impact the child’s life
• Symptoms were present prior to age 7 years
Proposed DSM-5 Criteria Changes
• The three subtypes of childhood ADHD will no longer be identified as separate conditions
• The age of onset will be extended up to age 12
• Reduction of symptom threshold for diagnosis from six to four symptoms
Assessment of suspected ADHD in children/adolescents Assessment Action/Tool Assess for ADHD Use the Vanderbilt scales
(Rating scales alone should not be used to make a diagnosis) Vanderbilt parent rating scale Vanderbilt teacher rating scale
Interview patient and parent (s) Confirm that symptoms:
Are causing impairment in at least two settings (e.g. home and school) Begin by age 7 years
Screen for psychiatric co morbidities
Additional screening for co morbidities
Assessment
Action/tool
Depression
PHQ-9 normed for children age 12 or greater
Anxiety
GAD-7 no adolescent norms
Drug/Alcohol Use:
CRAFFT
Learning Disabilities
• If a child is struggling in school, it may be due to ADHD, LD or both
• If a child is having moderate difficulty (passing classes, able to read but not completing assignments) consider ADHD treatment before assessment of LD
• If a child is having significant difficulty (failing classes, not being able to read) consider assessment of LD through the school.
Psychological testing
There is no psychological test that can diagnose ADHD Some ADHD children have executive functioning deficits (i.e. planning,
organization, working memory)
Can typically be detected through clinical interview
Psychological testing can help determine extent and severity of executive functioning deficits
Testing can help determine extent of co morbid disorders if not clarified in clinical
interview or rating scales.
Not recommended (diagnostic testing)
• Brain imaging (e.g. SPEC, PET scan, MRI, or CT) is NOT recommended for diagnosing childhood ADHD
Treatment
The primary treatment goal is to reduce (control, manage) ADHD symptoms and achieve a clinically appropriate level of stability and baseline functioning.
Establish the specific treatment goals with the parents and child
These goals will typically target specific behaviors at home and school
A multi-modal approach to treatment of ADHD by combining medication, behavioral modalities, parent education and school based interventions is recommended
Shared decision making for medication and behavioral treatments is recommended
Parent education and school based educational interventions are also recommended
Parent Support
www.chadd.org
• Detailed information about the causes, symptoms and treatment of ADHD. Includes an online magazine, information about support groups in the Puget Sound area, and books for purchase.
Pharmacologic Options
General approach
• Recommend shared decision making for pharmacologic treatment based on impairment type and parent/patient interviews
• Parents and patients should be informed of the benefits and harms of pharmacologic treatment
• The primary intervention for children under 5 years of age is behavioral therapy. ADHD medications are not generally recommended; consider consultation with or management by a child psychiatrist
• Prescribe no more than 3 months of medication at any one time• Provide medication coverage during school and homework hours. Most experts also
advise weekend dosing, as social and family function is as important as academic function.
Pharmacologic Options – continued
Medication Selection• Stimulant medication is the recommended first line treatment• What about increased cardiac risk with stimulants. Recent NEJM article found no
increased risk • Initiate medications at the lowest possible dose and titrate slowly. Before switching
medications, titrate to the maximum dose if there are no side effects.• If one stimulant is not working or produces too many adverse effects, try another
stimulant before using a different class of medications. Response to one stimulant does not predict response to others.
• Combining medications from two or more different drug classes is not recommended to treat the core symptoms of ADHD, though this practice may be used to treat other symptoms.
• Assess adolescents for substance abuse or diversions, initially before prescribing any medication and again before authorizing refills. If they are abusing or suspected of abusing drugs, prescribe a non-stimulant medication as a first-line treatment
Recommended pharmacologic options for children/adolescents aged 5 and older with ADHD
Medications Duration of behavioral
effects
Initial dose
Titration schedule
Maximum daily dose
Methylphenidate (generic Concerta) 10-12 hours 18 mg daily
Increase by 18 mg daily at weekly intervals
Ages 6-12: 54mg Ages 13-18: 72 mg
Methylphenidate ER (generic Methylin ER) 6 – 8 hours 10 mg daily
Increase by 10 mg daily at weekly intervals 60 mg
Dextroamphetamine SR 8 hours 5 mg daily
Increase by 5 mg daily at weekly intervals 40 mg
Amphetamine/Destroamphetamine mixed salts (Adderall XR) 8 – 12 hours 5 mg daily
Increase by 5 mg daily at weekly intervals 30 mg
Immediate-release ADHD medications 2,4
Methylphenidate 3 -4 hours2.5-5mg 1-2 times daily
Increase by 2.5-5mg daily at weekly intervals, split dose 3 times daily 60 mg
Dextroamphetamine 4-5 hours2.5-5mg 1-2 times daily
Increase by 2.5 – 5 mg daily at weekly intervals, split does twice daily 40 mg
Amphetamine/Dextroamphetamine mixed salts 4-6 hours
2.5-5mg 1-2 times daily
Increase by 2.5-5mg daily at weekly intervals, split does twice daily 40 mg
Non-stimulant ADHD medication (second –line medication first-line medication for special circumstances, such as substance abuse or diversion)
Medications Duration of behavioral effects
Initial Dose Titration schedule
Maximum daily dose
Atomoxetine PA (Strattera)5
8-24 hours Weight ≤ 70 kg: 0.5 mg/kg/day x 3 then 1.2 mg/kg/day
Weight ≥ 70 kg: 40 mg daily x 3 days, then 80 mg daily
All patients: single dose after dinner or split dose twice daily with food
1.4 mg/kg daily or 100mg whichever is less7
Guanfacine IR 16-24 hours 0.5 mg daily given at bedtime for a few nights, then twice daily
Increase by 0.5 mg daily at weekly intervals (in 1 to 2 doses)
4 mg daily
All ADHD patients on medication
Physical Changes• Weight• Height• Blood Pressure• Pulse
Medication tolerance and side effects
If patient develops any cardiac adverse effects on stimulants, stop the medication immediately and consider referral to Cardiology.
Children receiving doses that are too high or who are overly-sensitive to medications may become overly focused or appear dull.
Assess for medication rebound, especially for patient on short acting agents
All ADHD patients on medication
After initiation of medication
• Schedule follow-up office visit within 30 days
• Schedule additional visits every 1-2 months until medication effective doses is established
• Use Vanderbilt Rating Scale to track changes at home and school
Once a patient is stable on a medication and dose
• Telephone or secure email assessment every 3 months and when refills are requested
• Office visit every 6 months
If medication or dosing is changed
• Contact weekly via telephone or secure message until stable
Additional Medical Tips
• For children who do not respond to stimulants or strattera, consider consultation with Children’s/U of W child psychiatry Partnership Access Line (PAL) a telephone based child psychiatric consultation service. It is specifically designed for consultation for primary care providers in Washington State. While established for Medicaid population, consultation is available for any child under age 21.
Website: http://palforkids.org/
Phone number: 866-599-7257 8:00am-5:00pm M-F
Behavioral Modalities
• Combined pharmacological and behavioral therapy is no more effective than medication alone in reducing the primary symptoms of
ADHD: inattentiveness, hyperactive and impulsivity. • However, ADHD often has a secondary impact on social and especially school functioning. • Therefore, behavioral interventions may be appropriate if:
1. The family declines pharmacological treatment
2. Medication produces only partial remission of symptoms
3. There are co-morbid conditions that may not respond to stimulant medication treatment.
Parental Management Strategies
• Maintain a daily schedule with routine activities at the same time of day
• Limit sensory distractions (e.g. loud music, video games, computer and television)
• Create an organization plan for your house and have specific spots for leaving school work, toys, clothes, etc.
• Set small, attainable goals. Develop and use a visual system when possible
• Help your child stay on task with simple instructions and friendly reminders; congratulate them when they follow through
Parental Management Strategies - continued
• Limit choices. Your child will like options but limit them to two or three so your child does not feel overwhelmed or frustrated
• Find activities that can help promote social skills
• Find something that your child is good and help promote it (e.g. drawing, puzzles, Lego's, raising pets)
Parental Management Strategies - continued
• Reward positive behavior. Kind words, praise, hugs and small rewards both help promote appropriate behavior and help children feel good about themselves.
• Use calm discipline. Redirect children to another activity when they are being disruptive. Make sure your child is calm before talking to them about inappropriate behavior.
• Most importantly, enjoy your child by spending time with them, playing with them and doing fun activities.
Strategies for Managing ADHD in School
School is often the most difficult environment for a child with ADHD, as the ability to stay on task, be focused and avoid distraction is critical to being successful in school.
• The first step in ensuring success at school is finding the right teacher.
• Teachers who are nurturing and firm are often best type of teachers to work with ADHD children.
• Maintain close contact with the teacher• Have a good homework area away from distractions. • Set up a regular “study hour” free of electronics, when the parent (s)
are available for tutoring, support and encouragement
Laws that can help if the ADHD child is having trouble in school
Section 504 of the Rehabilitation Act protects the rights of people with disabilities
• Available to ADHD child as first step if not successful. Focuses on accommodations, not special ed. Typically needs diagnosis from physician. Accommodations can include:
– Extended time for testing and homework difficulties – Allow use of calculator and/or laptop – Tailoring and/or minimizing amount of homework assignments – Limiting repetitive homework – Preferential seating – Organizational assistance – Sometimes assigning note-taking or study buddy – Changing the delivery of tests – Use of behavioral management techniques
Laws that can help if the ADHD child is having trouble in school – continued
Individual with Disabilities Education Act of 1997 (IDEA)
• If implementing a 504 plan has not been successful IDEA services or special education may be appropriate.
• Parent or teachers can request evaluation for special education services if they feel the child may benefit from such services.
• There are specific steps dictated by state and federal law regarding what exactly occurs in terms of timeline and type of evaluation.
• In most circumstances, an evaluation must be completed within 30 days of the request and include observation of child and assessment of his or her academic and cognitive skills.
Laws that can help if the ADHD child is having trouble in school – continued
• ADHD is considered to be a health impairment which is one of the qualifying conditions for special education.
• Your child's physician may be asked to provide documentation of this diagnosis.
• If the child qualifies for special education, an individualized educational plan (IEP) is developed by school that addresses deficits identified in the evaluation.
• This educational plan includes measurable objectives that are reviewed by the school and the parents annually.
• Parents as well as the student (particularly if they are an adolescent) have opportunity to provide input into the plan.
Adult ADHD Characteristics
BEHAVIOR MANIFESTATIONS
1. Trouble focusing and concentrating
2. Easily distracted and sidetracked
3. Trouble finishing tasks
4. Themes of intense frustration and underachievement
5. Poor organizational and planning skills
6. Procrastination
7. Mental and physical restlessness
8. Impulsive decision making
9. Poor academic grades for ability
10. Chronic lateness
11. Frequently loses things
Adult ADHD Characteristics
Associated Features
1. Poor self-esteem
2. Academic underachievement
3. Peer relationship problems
4. Demoralization
5. Mood liability
6. Low frustration tolerance
7. Temper outbursts
8. Work problems
9. Increased auto accidents
10. More speeding tickets
ADHD in Adults
Prevalence:a. 30-40% of children with ADHD continue to have ADHD as adults,
so incidence of ADHD in adults is lower (1-3% population)b. Women represent a high proportion of the adult ADHD.c. Co morbid conditions tend to be more prevalent in adults with a higher
frequency of depression and anxiety disorders. Prevalence of these disorders are as follows:1. Oppositional Defiant Disorder 30%2. Learning Disabilities 25-30%3. Antisocial Personality Disorder 18% in males
8% in females4. Major Depressive Disorder 30-40%5. Bipolar Disorder 15%6. Anxiety Disorder 40-50%7. Alcohol and/or Drug Dependence 20-30%
Diagnosis of Adult ADHD
GENERAL APPROACH• Diagnosis is typically made by a mental health provider. Primary care
providers can make a diagnosis if they have expertise or training in adult ADHD. In addition:
– Masters level therapists can assess for adult ADHD.
– Psychologists can provide additional consultation if the clinical interview and rating scale data are not sufficient to clarify diagnosis
– Psychiatrists can provide consultation if there are additional questions regarding diagnosis/role of co morbid conditions, particularly if there are questions regarding psychopharmacological management.
Diagnosis is based on comprehensive clinical and psychosocial assessment, impact of symptoms on functioning, developmental history and review of rating scales.
Diagnosis - continued
• Rating scales alone are not sufficient to make a diagnosis of adult ADHD.
• Diagnosis requires determining that symptoms:
– Began in childhood and have persisted through life, and – Are not explained by other diagnoses, and – Have resulted in, or are associated with moderate or severe
psychological, social, and/or educational or occupational impairment
Screening for Adult ADHD
Eligible population Assessment Adult patients who have symptoms consistent with ADHD
Screen with the 6 item Adult ADHD Self-Report rating scale Ask additional follow-up questions: What difficulty are these symptoms causing in your life? How old were you when these symptoms first occurred? Screen for depression Use the first two questions of the PHQ-9. If the patient answers 2 or higher to either, use the full PHQ-9. Screen for alcohol and/or drug misuse or diversion. Use the Audit and DAST screen tools.
Cardiac Status: No evidence of relationship of stimulants to cardiac events, consider screening for cardiac event history
Adult Self-Report ADHD Rating Scale (available in public domain)
This Adult Self-Report Scale-V1.1 (ASRS-V1.1) Screener is intended for people aged 18 years or older.
Patient Name: Date:
Check the box that best describes how you have felt and conducted yourself over the past 6 months. Please give the completed questionnaire to your
healthcare professionals during your next appointment to discuss the results. Nev
er
Rar
ely
Som
etim
es
Ofte
n
Ver
y O
ften
1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
5. How often do you fidge; or squirm with your hands or feet when you have to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you were driven by a motor?
The 6 question Adult Self-Report Scale-Version1.1 (ASRS-V1.1) Screener is a subset of the WHO’S 18 question Adult ADHD Self-Report Scale. Version 1.1 (Adult ASRS-V1.1)Symptom Checklist. AT28491 PRINTED IN USA. 30C0054636 0903500 ASRSV1.1 Screener COPYRIGHT©2000 World Health Organization (WHO). Reprinted with permission of WHO. All rights reserved.
Screening Recommendations and Initial Primary Care Workup
Recommendations for screening for ADHD Eligible population Test Score Interpretation Adult patients suspected of having ADHD
6-item Adult ADHD Self-Report Scale (ASRS-V1.1) Primary care screening recommended for adult ADHD
0-3 marks the darkly shaded boxes
Unlikely to have ADHD, no need for additional evaluation
4 or more marks in the darkly shaded boxed
Symptoms suggest possibility of ADHD and need for additional evaluation
Diagnosis of ADHD Diagnostic approach Action Assess Clinical and psychosocial status Assess current mental status and review behavioral and
symptomatic concerns in the different settings of the person’s life.
Establish developmental history of ADHD Establish history of ADHD symptoms in childhood (preferably before the age of 7) either retrospectively or prospectively. Preferred: Use behavioral symptoms noted in school records or information from parents or sibling. Acceptable: Use patient self-report when collateral information is not available.
Assess impact of symptoms on functioning Confirm symptoms have clinically significant impact on social, educational or occupational functing. AND Confirm impairment exists in a least two different, important settings (e.g. home and work).
Diagnosis of ADHD Diagnostic approach Action Use rating scale Use the 18-item Adult Self-Report Scale
(PDF)(ASRS-V1.1); condier likelihood of ADHD if score on part A is 4 or more. The frequency scores in part B provide additional cues and can serve a further jporbes into the patient’s symptoms
Collect observer reports (e.g. partner, parent, friend)
Use interview or rating scale to corroborate presence of ADHD symptoms. Consider using the full version of the ASRA and modifying the language for observer usage.
Psychiatric Co morbidities
• Psychiatric Co Morbidities (i.e. depression, anxiety, substance use) are the norm rather than the exception. Consider use of Phq-9,
Gad-7, Audit, Dast.
• As with children, no psychological test to diagnose ADHD
• Psychological testing can be helpful for assessment of learning disabilities and in particular executive functioning deficits.
Not recommended (diagnostic testing)
• Brain imaging (e.g. SPEC, PET scan, MRI, or CT) is NOT recommended for diagnosing Adult ADHD
Education Adult ADHD patients
• It’s a chronic disease that waxes and wanes
• Very likely you have other problems (i.e. depression/anxiety) in addition to ADHD
• It’s a real disorder, YOU ARE NOT LAZY, STUPID OR CRAZY
• It’s something you can change and improve
• Though, there is not a cure for ADHD
• Treatment including medication AND lifestyle changes
Lifestyle Changes
• Establish structure and use devices (smart phone/lists) to help with reminders
• Pick vocations and hobbies that are of most interest• Establish a social supportive network (“it’s ok to have friends/family
help with reminding”)• Meet others with adult ADHD (“I am not alone”)• Eat well, sleep well and exercise• Substance use make ADHD symptoms worse. Develop a drug free
peer support network and/or seek treatment if necessary
Treatment: Pharmacological Options
Drug treatment should be the first-line approach for adults with ADHD with either moderate or severe levels of impairment, unless the patient would prefer a psychological approach (NICE 2008). Before initiation of stimulant treatment for adults with ADHD: • Inform patients that no clinical trials exist on long-term stimulant therapy
for adults with ADHD; the safety of long-term use is not known. • Inform patients of the risk of time-limited dysphoria if stimulant therapy is
discontinued after long-term use. • Inform patients of the other risks of stimulant therapy, including elevation
of blood pressure, cardiac arrhythmia and death, sleep disturbance, anorexia, mood or behavior disturbance, psychological dependence, and abuse potential.
• Cardiac Assessment: At least history ? Initiate ADHD medications at the lowest possible dose and titrate slowly. Before switching medications, titrate to the maximum dose (if there are no side effects).
Recommended pharmacologic options for adults with ADHD
Medication dosage forms Initial dose Titration schedule Maximum recommended
daily dose 1st line Recommended unless patient has a history of substance misuse or diversion with risk for relapse or a cardiac or other medical condition for which stimulants would be contraindicted. Methylphenidate HCL ER or
10 mg daily in the morning
Increase by 10 mg every 7 days (typically dosed twice daily) as needed
60 mg
Methylphenidate HCL ER (generic Concerta)
18 mg daily in the morning
Increase by 10 mg every 7 days (typically dosed twice daily) as needed
40 mg
2nd line Alternative recommendation unless patient has a history of substance misuse or diversion with risk for relapse or a cardiac or other medical condition for which stimulants would be contraindicted. Amphetamine mixed salts (Adderall XR) Or
10 mg daily in the morning
Incread by 10 mg every 7 days as needed
60 mg
Recommended pharmacologic options for adults with ADHD - continued
Medication dosage forms Initial Dose Titration schedule
Maximum recommended daily
dose 2nd line – continued Dextroamphetamine SR
10 mg daily in the morning
Increase by 10 mg every 7 days (typically dosed twice daily) as needed
40 mg
3rd line First line for patients if stimulants are contraindicted (e.g. cardiac condition or history of substance misuse or diversion) Atomoxetine (Strattera) {PA}
40 mg daily in the morning
Increase to 80 mg after ≥ 3 days. May increase to 100 mg after 2-4 additional weeks as needed
100 mg
Recommended pharmacologic options for adults with ADHD
Medication dosage forms Initial dose 1 Titration schedule
Maximum recommended daily dose
Other alternatives First-line agent for patients with a history of substance misues of diversion with risk for relapse (unless the patient is abusing alcohol) Bupropion IR or
100 mg twice daily x 7 days, then increase three times daily
After 4 weeks at 100mg three times daily, incrase to 200 mg twice daily
450 mg (IR)
Bupropion SR or
150 mg daily in the morning x 7 days, then increase to 150 mg twice daily (Consider starting at lower doses (e.g. 100mg})
After 4 weeks at 150 mg twice daily, increase to 200 mg twice daily
400 mg (SR)
Bupropion XR 150 mg daily in the morning
After 4 weeks at 150 mg daily, increase to 300 mg daily
450 mg (XR)
Follow Up/Monitoring
At all follow up visits:• Assess whether the patient’s behavior or functional goals are met• Consider using the 6 item ASRS to determine degree of treatment effectiveness
Medication Monitoring
Recommended medication monitoring Medication Items to monitor Frequency All Medications Medication adherence
Treatment effectiveness Adverse impact on sleep or behavior Adverse impact on appetite or weight
1. Initially and while titrating dosage, monitor every 3-4 weeks
2. Then, every 3 months until stable 3. Once stable, every 6 months
Stimulants Blood pressure Heart rate Evidence of abuse or diversion potential
Atomoxetine Blood pressure Neuropsychiatric effects(e.g. anxiety, irritability, hypomania, suicidal ideation)
Bupropion Blood pressure Neuropsychiatric effects (e.g. anxiety, irritability, hypomania, suicidal ideation)
Cognitive Behavioral Therapy (CBT)
Optimally, CBT should be combined with pharmacological treatments that improve the core ADHD symptoms of inattention, impulsivity, hyperactivity, and/or distractibility. Consider CBT when:
• It can be used in combination with medications, or especially when medications alone have proved to be only partially effective or ineffective. • The patient has made an informed choice not to use medications or is
intolerant of them. • The patient has difficulty accepting the diagnosis of ADHD and adhering to
a medication regimen. • The patient has a co morbid condition such as depression or anxiety that
could benefit from CBT. • Symptoms are remitting and psychological treatment is considered sufficient for targeting residual (mild-to-moderate) functional impairment.
CBT for ADHD Skills Details of teaching Organization and Planning Promote consistent ues of organizational aids such as calendars,
checklists, electronic devices, whiteboards, sticky notes, etc. Develop triage system for mail and other pages Structure the day and the environment
Problem solving Develop problem-solving skills Learn to look at a situation rationally Learn to adaptively think about problems and stressors through positive
self-talk Learn to identify and disrupt negative thoughts
CBT for ADHD - continued Skills Details of teaching Distraction management Build and maximize one’s attention span. This includes
breaking tasks into smaller steps that correspond with an individual’s attention span
Learn to effectively use a timer and other distractibility reminders
Procrastination management Develop motivational skills to deal with problems with procrastination
Not Recommended (Non-Pharmacologic Options)
• Elimination of sugar, salicylates, or artificial coloring from diet • Nutritional supplements such as Glyconutritional supplements, fatty acid
supplementation, mega dose vitamins, amino acid supplementation, or herbals
• Sensory integration training • Anti-motion sickness medication • Anti-fungal medication for Candida • Chiropractic treatments • Optometric vision training • Metronome training • Neuro/biofeedback
Web Sites
• A.D.D. Warehousewww.addwarehouse.com Books for purchase and other resources.
• Attention Deficit Disorder Resourceswww.addresources.org Books for purchase and other reading material, links to more web sites, and information about support groups in the Puget Sound area.
• Children and Adults with Attention Deficit/Hyperactivity Disorder www.chadd.orgDetailed information about the causes, symptoms and treatment of ADHD. Includes an online magazine, information about support groups in the Puget Sound area, and books for purchase.
• Helpguide.orgwww.helpguide.orgResources and references for adult ADD/ADHD self-help.
Evidence/References
• Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA). Canadian ADHD Practice Guidelines, Third Edition. 2011. Available online at: http://www.caddra.ca/cms4/pdfs/caddraGuidelines2011.pdf [PDF]
• Kooij S, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European
Network. BMC Psychiatry. 2010;10:67. Available online at: http://www.biomedcentral.com/content/pdf/1471-244x-10-67.pdf [PDF]
Evidence/References - continued
Additional information was pulled from these sources: • National Institute for Health and Clinical Excellence (NICE).
Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. NICE Clinical Guideline 72. 2008. Available online at: http://www.nice.org.uk/CG72
• Nutt DJ, Fone K, Asherson P, et al. Evidence-based guidelines for management of attention-deficit/hyperactivity disorder in adolescents in transition to adult services and in adults. J
Psychopharmacol. 2007;21(1):10–41. Available online at: http://www.bap.org.uk/pdfs/ADHD_Guidelines.pdf [PDF]
References
• Centers for Disease Control and Prevention (CDC). Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children-United States, 2003 and 2007. MMWR. 2010;59(44):1439–1443.
• Cooper et al., ADHD drugs and serious cardiovascular events in children and young adults, New England Journal of Medicine. 2011, 10, 1056-1066.
• Faraone SV. Using meta-analysis to compare the efficacy of medications for attention-deficit/hyperactivity disorder in youths. PT. 2009;34(12):678–694
• Faraone SV, Buitelaar J. Comparing the efficacy of stimulants for ADHD in children and adolescents using meta-analysis. Eur Child Adolesc Psychiatry. 2010;19(4):353–364.
• Institute for Clinical Systems Improvement (ICSI). ADHD, attention deficit hyperactivity disorder in primary care for school-age children and adolescents, diagnosis and management (guideline). 8th edition, March 2010.
• Kaiser Permanente. Child/adolescent attention deficit/hyperactivity disorder (ADHD) clinical practice guideline. December 2009.
References - continued
• Keen D, Hadjikoumi I. ADHD in children and adolescents (updated). Clin Evid. 2011;02:312.
• Molina BS, Hinshaw SP, Swanson JM, et al. The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. J Am Child Adolesc Psychiatry. 2009;48(5):484–500.
• The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56(12):1073–1086.
• National Institute for Health and Clinical Excellence (NICE). Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in children, young people and adults (guideline). September 2008.
• Raz R, Gabis L. Essential fatty acids and attention-deficit-hyperactivity disorder: a systematic review. Dev Med Child Neurol. 2009;51(8):580–592.
• Van der Oord S, Prins PJ, Oosterlaan J, Emmelkamp PM. Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: a meta-analysis. Clin Psychol Rev. 2008;28(5):783–800.
Books
• Mastering Your Adult ADHD, A Cognitive Behavioral Treatment Program, Client Workbook, by Safren, Sprich, Perlman, and Otto
• Delivered from Distraction by Hallowell and Ratey
• Women with Attention Deficit Disorder: Embrace Your Difference and Transform Your Life by Solden
Other Web Based Resources
• A.D.D. Warehousewww.addwarehouse.com Books for purchase and other resources.
• Attention Deficit Disorder Resourceswww.addresources.org Books for purchase and other reading material, links to more web sites, and information about support groups in the Puget Sound area.
• Learning Disabilities Association of America (LDA)www.ldanatl.org Information, resources, and support for learning disabilities for parents/teachers.
• Washington PAVEwww.wapave.orgCommunity-based program for parents of children with disabilities.