IAP NATIONAL GUIDELINES ATTENTION DEFICIT HYPERATIVITY DISORDER

[ADHD]INDIAN PEDIATRICS JUNE 2017

INDIAN ACADEMY OF PEDIATRICSCOMMITTEE ON CHILD DEVELOPMENT &

NEURO DEVELOPMENTAL DISORDERS

IAP CHAPTER OF NEURO DEVELOPMENTAL PEDIATRICS

DR SS KAMATH DR SAMIR DALWAI

IAP ACTION PLAN 2018-19

IAP ACTION PLAN 2018-19 PRESIDENT IAP 2018 DR SANTOSH SOANS

PRESIDENT ELECT 2018 DR DIGANT SHASTRI

HON. SECRETARY GENERAL IAP 2018 DR REMESH KUMAR

CONVENER DR SAMIR DALWAI

ADVISORS DR MKC NAIRDR SS KAMATH DR PRATIBHA SINGHI

DR NANDINI MUNDKURDR BAKUL PAREKH

DR ABRAHAM PAULDR JEESON UNNI DR JAGDISH CHINAPPA

COMMITTEE OF EXPERT CONTRIBUTORS

DR SS KAMATH DR HANUMANTHA RAO

DR UDAY BODHANKAR DR MADHURI KULKARNI

DR ABRAHAM PAULDR VEENA KALRA

DR NANDINI MUNDKURDR SHABINA AHMED

DR VRAJESH UDANIDR SAMIR DALWAI

DR S SITARAMANDR BAKUL PAREKH

DR SIVAPRAKASANDR PRAVIN MEHTA

DR NEETA NAIKDR KERSI CHAWDA

DR CHHAYA PRASADDR ZAFAR MEENAI

DR LEENA SHRIVASTAVADR LEENA DESHPANDE

DR ANJAN BHATTACHARYA DR ANURADHA SOVANI DR MONICA JUNEJA

DR KATE CURRAWALADR MAMTA MURANJANDR MONIDEEPA BANERJEE

With the Blessings of Prof MKC Nair, Vice Chancellor Kerala University of Health Sciences, the IAP National Guidelines were released at Pedicon 2016 at Hyderabad.

TERMINOLOGY

1. ADHD is a disorder that manifests in early childhood with symptoms of hyperactivity, impulsivity, and or inattention. 1. The Symptoms affect

1. Cognitive 4. Emotional 2. Academic 5. Social Functioning 3. Behavioral

2. ADHD is a chronic condition and children and adolescents with ADHD are to be considered as children and youth with special health care needs.

AETIOLOGY

1. ADHD has a genetic and biochemical basis.

2. The role of environmental factors is not certain;

they may influence symptoms of ADHD (sub

syndromic) rather than the syndrome of ADHD.

DEVELOPMENTAL SURVEILLANCE

A process that involves:

1. Eliciting and addressing parent’s concerns at every

well-visit

2. Monitoring milestones in development, behavior at

every well-visit

3. Identifying (and continuing to look for) risk factors

1. Screening is the process of identifying children who may

be at increased risk of a disease or condition (ADHD).

2. The screening provider then offers information, further

tests and treatment.

3. The Pediatrician should monitor for both medical and

mental health concerns and provide appropriate

treatment or referral as indicated.

SCREENING

Prevalence in India

• Reported Prevalence Varies

• 11.3% ( 2013 study from Southern India in Primary School

Children)

• 32.4% ( 2009-2012 from Mumbai – retrospective data

retrieved)

RECOMMENDED SCREENING TOOLS

1. CBCL

2. CONNORS

3. VANDERBILT

4. INCLEN

CORE CLINICAL FEATURES

ADHD is a syndrome with two categories of core symptoms:

• INATTENTION (I)

• HYPERACTIVITY-IMPULSIVITY (HI)

CORE CLINICAL FEATURES

1. Each of these core symptoms of ADHD has its own pattern

and course of development.

2. Complaints regarding symptoms of ADHD may originate

from the parents, teachers, or other caregivers.

3. It is important to discuss safety and injury prevention at

each visit.

SYMPTOMS- AGE OF PRESENTATION

• HI - Typically observed by the time the child reaches 4 years of

age.

• I - Typically identified late and not apparent until the child is 8

to 9 years of age.

CLINICAL SUBTYPES

1. Predominantly HI

2. Predominantly I

3. Combined

HYPERACTIVITY AND IMPULSIVITY

1. Hyperactive and impulsive behaviors almost always occur

together in young children.

2. The predominantly hyperactive-impulsive subtype of ADHD

is characterized by the inability to sit still or inhibit behavior.

ONSET AND PROGRESS

1. Typically observed by 4 years of age. However, younger presentation of symptoms are being increasingly reported.

2. Symptoms increase during the next 3 to 4 years, peak at 7 to 8 years of age.

3. Thereafter, hyperactive symptoms begin to decline; by the adolescent years, they may be hardly recognizable although the adolescent may feel restless or unable to settle down. ( In contrast, impulsive symptoms usually persist throughout life.)

4. The focus of impulsivity is always influenced by the child's environment.

SYMPTOMS OF HI (DSM 5)

1. Excessive fidgetiness (squirming in seat, tapping the hands or feet)

2. Difficulty remaining seated when sitting is required (at school, work, etc)

3. Feelings of restlessness (in adolescents) or inappropriate running around or climbing (in preschool children)

4. Difficulty playing quietly5. Difficult to keep up with, seeming to always be “on the go”6. Excessive talking7. Difficulty waiting turns8. Blurting out answers too quickly9. Interruption or intrusion of others

HYPERACTIVITY Manifests as: 1. Excessive motor activity

a . E x c e s s i v e f i d g e t i n gb . T a p s h a n d s o r fe e t o r s q u i r m s i n s e a t .c. Leaves seat in situations when remaining seated is

expected e.g. leaves school , classroom, work place.d. R u n s a b o u t o r c l i m bs i n s i t u at i o n s w h e re i t i s

inappropriate.e. Unable to play or engage in leisure activities.f. Acting as if driven by a motor and may be experienced by

others as if restless, e.g. unable to be / uncomfortable being still for extended time in place where quietness required.

2. Talks excessively and incessantly

IMPULSIVITY Manifests as: Hasty actions:

1. That occur in the moment without fore thoughta. Speech related : blurting out an answer before a

question has been completed./ completing people's sentences/ butting into the conversation and difficulty waiting for turn in conversation

b. Actions : Difficulty waiting for his or her turn/ wants to be first

2. May have high potential for harm /accidents to the child (darting into the street without looking)

3. May manifest as social intrusiveness (interrupting others excessively)

IMPULSIVITY Manifests as:

4. Making important decision without consideration of long

term consequence (taking up a responsibility / job without

adequate consideration)

5. Difficulty waiting her or his turn (while waiting in line)

6. Interrupts or intrudes on others (butts into conversations,

games or activities; may start using other people’s things

without asking permission)

INATTENTION

1. The predominantly inattentive subtype of ADHD is

characterized by

a. reduced ability to focus attention and

b. reduced speed of cognit ive process ing and

responding.

2. These symptoms are not due to defiance (disobedience

or rebelliousness) or lack of comprehension

SYMPTOMS OF INATTENTION (DSM 5)

1. Failure to provide close attention to detail, careless mistakes2. Difficulty maintaining attention in play, school, or home activities3. Seems not to listen, even when directly addressed4. Fails to follow through (homework, chores, etc)5. Difficulty organizing tasks, activities, and belongings6. Avoids tasks that require consistent mental effort7. Loses objects required for tasks or activities (school books, sports

equipment, etc)8. Easily distracted by irrelevant stimuli9. Forgetfulness in routine activities (homework, chores, etc)

ONSET

• Typically identified late and not apparent until the child is 8 to 9 years of age.

• This delay may be due to – Poor awareness of caregivers about attention problems – Increased variability in the normal development of the

cognitive skills

PROGRESS

• Similar to the pattern of impulsivity, symptoms of inattention usually are a lifelong problem.

INATTENTION manifests as 1. Overlooks or misses details or makes careless mistakes

with inaccuracies ina. Schoolworkb. During routine activitiesc. At office

2. Has difficulty in sustaining attention in tasks a. During lectures b. Lengthy reading

3. May have difficulty in sustaining attention in play activities4. May have difficulty in sustaining attention even during

conversations

INATTENTION Manifests as

5. Does not seem to listen when directly spoken to and the mind seems elsewhere even without any obvious distraction.

6. Does not follow instructions and fails to finish schoolwork, chores, duties in work place.

7. Wandering off task : The child starts tasks but quickly loses focus and easily gets side tracked.

8. Lacking persistence.

INATTENTION Manifests as 9. Difficulty in organizing tasks and activities

a. Managing sequential tasksb. Keeping materials and belongings in orderc. Disorganized workd. Poor time managemente. Fails to meet dead lines

10. Avoids, reluctant to engage in task that require sustained mental efforta. School work / home workb. Completing formsc. Reviewing lengthy papers

INATTENTION Manifests as

11. Loses things necessary for tasks and activities (toys, school materials, books, pencils, wallets, mobile, keys)

12. Easily distracted by external stimulia. Outside sounds of animals, birds, airplane / Kids playing

outside the classb. Older adolescents and adults: unrelated thoughts

13. Forgetful in daily activities (Daily chores, attending classes, running errands, returning calls, paying fees, keeping appointments)

IMPAIRED FUNCTIONING

1. In order to be diagnosed as ADHD, core symptoms must impair function in academic, social, or occupational activities.

2. Social skills often are significantly impaired. 3. Problems with inattention may limit opportunities

to acquire social skills or to attend to social cues necessary for effective social interaction, making it difficult to form friendships.

4. Hyperactive and impulsive behaviors may result in peer rejection.

IMPAIRED FUNCTIONING

5. The negative consequences of impaired social function (poor self-esteem, increased risk for depression and anxiety) may persist life-long.

6. Similarly, the negative consequences of impaired academic achievement (poor reading, writing, arithmetic skills) may significantly disadvantage eventual academic achievement.

7. Early Diagnosis is essential to prevent further compromise of functional achievement.

PRESCHOOL CHILDREN

1. High Activity level/ Poor inhibitory control / Short Attention Span common in normal children a) Increased Precarious Behaviors & Physical Injuriesb) Unmanageable Behaviors across settings c) Poor performance at school, laterd) Associated with ODD/ Anxiety/ Communicat ion

Disorders

2. Combined Type most common, Inattentive Type is rarely diagnosed

3. Persists in 60-80% in school age children

SCHOOL AGE CHILDREN

1. Inattention relatively stable

2. Hyperactivity decreases

3. 70 % have co morbidities

4. Major impacts on

a. Peer Interactions

b. Family Interactions

c. Academics

• Persistence of ADHD at age 25 years

– Meeting full criteria for ADHD - ~15%

– ADHD in partial remission (DSM 4) - ~65%

• Symptoms of Inattention persist more and show slower

decline

COMORBID DISORDERS WITH ADHD

1. Oppositional Defiant Disorder co-occurs with ADHD in a half of children with combined presentation and one quarter with inattentive presentation.

2. Conduct disorders -~25% of children or adolescents with combined presentation.

3. Specific learning disorder -70%4. Anxiety disorders and major depressive disorders occur in

minority of individual with ADHD.5. Intermittent explosive disorders, substance abuse disorder -

minority of adults (but at rates above populations levels).6. Antisocial disorder, obsessive compulsive disorders, tic

disorders and ASD (40%)

OPPOSITIONAL DEFIANT DISORDER

Recurrent negative, defiant, disobedient, and hostile behavior toward authority figures, including1. Losing temper2. Arguing with adults3. Actively defying or refusing to comply with adults'

requests or rules4. Deliberately annoying people5. Blaming others for his or her mistakes or misbehavior6. Being touchy or easily annoyed by others7. Being angry and resentful8. Being spiteful or vindictive

ANXIETY DISORDER

Persistent, excessive, difficult to control worry about events or activities; associated with1. Restlessness2. Easy fatigability3. Difficulty concentrating4. Irritability5. Muscle tension6. Sleep disturbance

DEPRESSION

Persistent disturbance in emotions, ideation, or somatic symptoms as indicated by ≥5 of the following symptoms; at least one of the symptoms in red must be present:1. Depressed or irritable mood2. Markedly diminished interest or pleasure in almost all activities3. Change in appetite or weight4. Insomnia or hypersomnia5. Psychomotor agitation or retardation6. Fatigue or loss of energy7. Feelings of worthlessness or guilt8. Impaired concentration, indecisiveness9. Recurring thoughts of death or suicide

LEARNING DISABILITY

Intrinsic cognitive difficulty that results in lower academic achievement than expected for intellectual potential, include1. Reading disorder2. Disorder of written language3. Mathematics disorder4. Learning disorder, not otherwise specified

CONDUCT DISORDER

Repetitive and persistent violation of age-appropriate societal norms, rules, or basic rights of others; includes

1. Aggression to people and animals2. Destruction of property3. Deceitfulness or theft4. Serious violations of rules

DIAGNOSIS OF ADHDDSM- 5

1. For children <17 years, ≥6 symptoms of hyperactivity and impulsivity or ≥6 symptoms of inattention. For adolescents ≥17 years and adults, ≥5 symptoms of hyperactivity and impulsivity or ≥5 symptoms of inattention are required.

2. Persisting for 6 months3. Negatively impacts

a. Psychologicalb. Socialc. Academicd. Occupational activities

DIAGNOSIS OF ADHDDSM - 5

4. Inconsistent with developmental level of child5. Symptoms of I/HI start before 12 years 6. Symptoms of pervasive I/HI in two or more settings

(home/school/work/playground/neighbour’s home)7. Type of subtype to be specified (I/HI/ Combined). The

subtype of ADHD in a given patient can change from one to another over time .

8. Severity of the condition can be determined based on impairment in

a. Social b. Occupational c. Academic functioning

DIAGNOSIS OF ADHDDSM - 5

9. Evaluation should include assessment for CO-MORBID CONDITIONS that might coexist with ADHD, including

a. Emotional or behavioural disorders (e.g. anxiety, depressive, oppositional defiant, and conduct disorders)

b. Developmental disorders (e.g. learning and language disorders or other neurodevelopmental disorders)

c. Physical disorders (e.g. tics, sleep apnoea) conditions

10. Rule out other causes of core symptoms

SPECIAL CASES

1. Diagnosis in PRESCHOOL CHILDREN The diagnostic criteria for ADHD (without subtyping) can be applied to children as young as 4 years of age. (AAP 2011)

2. Diagnosis in ADOLESCENTSAdolescents may underreport core symptoms or functional impairment and may spend too little time at home for parents to be accurate informants. Hence, the Pediatrician must obtain information from at least two teachers and/or other adults with whom the adolescent interacts (e.g. counselor, coaches, etc) (AAP 2011)

DIFFERENTIAL DIAGNOSIS

The symptoms of ADHD overlap with a number of

other conditions, including

1. Developmental variations

2. Neurologic or developmental conditions

3. Emotional and behavioral disorders

4. Psychosocial or environmental factors

5. Medical conditions

DIFFERENTIAL DIAGNOSIS - 1

DEVELOPMENTAL VARIATIONS METHODS TO DISTINGUISH FROM ADHD

Intellectual disability Psychometric testing

Giftedness Psychometric testing

Normal variation History

DIFFERENTIAL DIAGNOSIS - 2NEUROLOGIC OR DEVELOPMENTAL CONDITIONS

METHODS TO DISTINGUISH FROM ADHD

Learning disability Psychometric testing

Language or communication disorder Psychometric testing

Autism spectrum disorders History; structured observation

Neurodevelopmental syndromes (eg, fetal alcohol syndrome, fragile X syndrome) History; examination; genetic testing

Seizure disorder History; electroencephalography

Sequelae of central nervous system trauma or infection History

Motor coordination disorder History; examination; occupational therapy evaluation

DIFFERENTIAL DIAGNOSIS - 3

EMOTIONAL/BEHAVIORAL DISORDERS METHODS TO DISTINGUISH FROM ADHD

Depression or mood disorder Psychological evaluation

Anxiety disorder Psychological evaluation

Oppositional defiant disorder Psychological evaluation

Conduct disorder Psychological evaluation

Obsessive compulsive disorder Psychological evaluation

Post-traumatic stress disorder Psychological evaluation

DIFFERENTIAL DIAGNOSIS - 4

PSYCHOSOCIAL OR ENVIRONMENTAL PROBLEMS METHODS TO DISTINGUISH FROM ADHD

Child abuse or neglect History; examination

Stressful home environment Family history; socio economic details

Inadequate or punitive parenting Family history

Parental psychopathology or substance abuse Family history

Inappropriate educational setting Symptoms occur only at school but not at home

Frequent school absence Psychosocial history

DIFFERENTIAL DIAGNOSIS - 5

MEDICAL CONDITIONS METHODS TO DISTINGUISH FROM ADHD

Hearing or vision impairment Hearing and vision examination

Sleep disorder History; sleep study if indicated

Iron deficiency anemia Complete blood count and other hematologic evaluation

Lead poisoning Blood lead level

Endocrine disorders (e.g.thyroid disease, diabetes mellitus) Laboratory evaluation

Cardiac disorders (e.g. heart failure) Medical history; echocardiograph/pediatric cardiology consultation

Substance abuse History; toxicology evaluation

Food allergy History; allergy testing

Undernutrition Anthropometry

Medication side effects Detailed history

EVALUATION AND ASSESSMENTS

1. Any child 4 through 18 years of age who presents with academic or behavioural problems and symptoms of inattention, hyperactivity, or impulsivity should be evaluated (AAP 2011)

2. Information should be obtained from parents or guardians, teachers, and other school and mental health clinicians involved in the child’s care

COMPREHENSIVE EVALUATION FOR ADHD

A. Confirm CORE SYMPTOMS1. Presence2. Persistence3. Pervasiveness4. Functional Complications

B. Exclude Other Explanations for CORE SYMPTOMS (DD)C. Identify COEXISTING DISORDERS

1. Emotional2. Behavioral3. Medical disorders

COMPREHENSIVE EVALUATION FOR ADHD INCLUDES

1. Review of Medical, Social, and Family histories

2. Clinical interviews with the parent and patient

3. Information about functioning in school or day care

4. Evaluation for coexisting emotional or behavioral

disorders

MEDICAL EVALUATION

Important aspects of the medical history include 1. Prenatal exposures (tobacco, drugs, alcohol)2. Peri natal complications or infections3. Head trauma4. Central nervous system infection5. Recurrent Otitis Media6. History of sleep disturbances7. Family history of similar behaviors 8. Medications9. Detailed child and family cardiac history before initiating

medications

PHYSICAL EXAMINATION

1. Normal in most children with ADHD2. Vision and Hearing assessment3. Rule out differential diagnosis4. Document at each visit:

a. Measurement of height, weight, head circumference, and vital signs

b. Assessment of dysmorphic features and neuro-cutaneous abnormalities

c. A complete neurologic examinationd. Observation of the child's behavior in the clinic

DEVELOPMENTAL AND BEHAVIORAL EVALUATION

1. History of a. age of onset of the core symptoms of ADHDb. duration of symptomsc. settings in which the symptoms occurd. degree of functional impairment and functional impact

of ADHD symptoms2. Developmental milestones, especially language milestones3. School absences4. Psychosocial stressors5. Emotional, medical, and developmental events that may

provide an alternative explanation for the symptoms

DEVELOPMENTAL AND BEHAVIORAL EVALUATION

6. Observation of parent-child interactions in the office7. Information about the core symptoms can be obtained

through the use of open-ended questions or from ADHD-specific rating scales.

8. The Pediatrician must document the presence of the relevant behaviors from the DSM-5.

EDUCATIONAL EVALUATION

Documentation of the core symptoms in the educational setting:

1. Completion of an ADHD-specific rating scale

2. A detailed summary of classroom behavior and interventions, learning patterns, and functional impairment from the school

3. Environmental factors (eg, different expectations, levels of structure, or behavior management strategies) may be contributing to these symptoms.

THE ROLE OF THE PEDIATRICIAN

1. Children with ADHD, 4 to 18 years of age, without co morbid

condit ions can usual ly be managed by the pr imary

pediatrician.

2. Management begins with evaluation of the cl inical

presentation and the diagnosis, as per the DSM 5 criteria

and the enunciation of coexisting conditions (co morbidities).

1. Completion of these scales by parents and teachers during the diagnostic evaluation helps to establish the presence of core symptoms of ADHD in more than one setting.

2. ADHD-specific rating scales – (also called narrow-band scales since they focus directly on the symptoms of ADHD) can be used to establish the presence of the core symptoms of ADHD.

AIM OF MANAGEMENT

MANAGEMENT OF ADHD

1. Chronic condition. 2. Education of patients, families, and teachers regarding the

diagnosis is an integral part of management. Involvement of patient and family is extremely vital.

3. Management of ADHD centers on the achievement of target outcomes, which are chosen in collaboration with the child, parents, and school personnel.

4. Coexisting conditions must be treated concurrently with ADHD.

5. Modalities of management of ADHD include behavioral/ psychological interventions, medication, and/or educational interventions, alone or in combination.

BEHAVIORAL INTERVENTIONS (BI)

1. Behavioral interventions are modifications in the physical and social environment that are designed to change behavior by using rewards and nonpunitive consequences

2. Parent-child behavioral therapy is aimed at improving parent-child relationships through enhanced parenting techniques

3. Behavioral interventions are most effective if parents understand the pr inc iples of behavior therapy ( ie , identification of antecedents and altering the consequences o f be hav ior ) an d t h e te c h n i q u e s a re co n s i ste nt l y implemented

1. Initial intervention for preschool children with ADHD

(preferred to medication)

2. Adjunct to medication for school-aged children and

adolescents with ADHD

3. Can be used for chi ldren who have problems with

inattention, hyperactivity, or impulsivity but do not meet

criteria for ADHD (sub syndromic)

INDICATIONS

BEHAVIORAL INTERVENTIONS INCLUDE:

1. Positive reinforcement

2. Time-out

3. Response cost (withdrawing rewards or privileges

when unwanted or problem behavior occurs)

4. Token economy (a combinat ion of pos i t ive

reinforcement and response cost)

Useful For Parents And Teachers To Help Children With ADHD Regulate Their Own

Behavior

1. Maintaining a daily schedule (time table, post- its, reminders)2. Using charts and checklists to help the child stay "on task"3. Keeping distractions to a minimum4. Limiting choices5. Providing specific and logical places for the child to keep his schoolwork,

toys, and clothes6. Setting small, reachable goals 7. Rewarding positive behavior (e.g. with a “token economy”)8. Identifying unintentional reinforcement of negative behaviors9. Finding activities in which the child can be successful (e.g. hobbies,

sports)10. Using calm discipline (e.g. time out, distraction, removing the child from

the situation)

EDUCATIONAL INTERVENTIONS

Children with ADHD may require changes in their educational

programming, including

1. Provision of tutoring or resource room support (either in an

one-on-one setting or within the classroom)

2. Classroom modifications

3. Accommodations

4. Behavioral interventions

CLASSROOM MODIFICATIONS AND ACCOMMODATIONS INCLUDE

1. Having assignments written on the board2. Sitting near the teacher3. Having extended time to complete tasks4. Being allowed to take tests in a less distracting environment5. Receiving a private signal from the teacher when the child is

"off-task"6. Being assigned a "Study Buddy"7. Being assigned a "Shadow Teacher"

• The teacher may submit a regular (daily/weekly) report card that helps to monitor symptoms and the need for changes in the treatment plan.

FOR PRESCHOOL CHILDREN (AGE 4 THROUGH 6 YEARS)

1. Behavioral Intervention(BI), rather than medication, is the initial therapy .

2. Addition of medication is indicated if target behaviors do not improve with BI and the child’s function continues to be impaired.

3. Methylphenidate is preferred rather than amphetamines or non stimulants.

FOR SCHOOL-AGED CHILDREN (≥6 YEARS) AND ADOLESCENTS

1. Treatment with medication rather than - BI alone or no intervention.

2. A Stimulant is the first line agent. Non Stimulants are the second line agent.

3. BI should be added to medication therapy. 4. Adding behavioral/ psycho logic therapy to stimulant therapy

in school-aged children and adolescents does not provide additional benefit for core symptoms of ADHD, but has an impact ona. symptoms of coexisting conditions

(e.g. oppositional/aggressive behavior) b. educational performancec. the dose of stimulant therapy necessary to achieve the desired effects.

CHOICE OF MEDICATION

1. Preschool child (if indicated): Stimulant (Methylphenidate) 2. School-aged child or adolescent : A Stimulant is the first-line

agent fo l lowed by amphetamines or non st imulant (Atomoxetine).

3. Other medications (e.g. alpha-2-adrenergic agonists) usually are used whena. Children respond poorly to a trial of stimulants or

Atomoxetineb. Have unacceptable side effectsc. Have significant coexisting conditions

4. Duration of action5. The child's ability to swallow pills

Stimulants

1. Stimulants are preferred to other medications because

stimulants have a rapid onset of action and long record of

safety and efficacy.

2. Individual differences in metabolism are more significant

than weight-based dosing of stimulant medications.

3. The optimal regimen is determined by changes in core

symptoms and occurrence of side effects.

1. Stimulant medications usually are started at the lowest dose

that may produce an effect and increased gradually (every

three to seven days) until core symptoms improve by 40 to

50 percent compared with baseline, or adverse effects

become unacceptable.

2. The frequency of stimulant medication (both times per day

and days per week) is based upon the type of ADHD and the

domains of function in which improvement is desired.

Stimulants

Frequency of dosing

1. A child with the predominantly inattentive type of ADHD may

need medication only on school days.

2. A child who has difficulty with peer relationships may need

medication every day.

3. A child who participates in after-school sports or activities on

certain days of the week may require longer-act ing

preparations or more frequent dosing on those days.

4. Optimal dose is the dose at which target outcomes are

achieved with minimal side effects.

Methylphenidate 5, 10, 20 mg tablets

1. Duration of action: 3 to 5 hours

2. Dosage: Start with 5 mg/day x 1 day; then 5 mg 2 times per

day

3. (Children ≤25 kg may be started with 2.5 mg per day)

4. Increments of 5 mg per day every 3 to 7 days

5. (Children ≤25 kg may be increased by 2.5 mg per day every 3

to 7 days)

6. Maximal Dose: ≤25 kg: 35 mg; >25 kg: 60 mg

Atomoxetin( non – stimulant) (10, 18, 25mg)

1. Duration of action: At least 10 to 12 hours

2. Dosage:

3. Start with 0.5 mg/kg per day for minimum of 3 days

4. Increase to 1.2 mg/kg per day after a minimum of 3 days

(maximum 100 mg per day or or 1.4 mg/kg whichever is

lesser)

Duration of Medication

1. After several years of medication, children and adolescents who have had stable improvement in ADHD symptoms and target behaviors are offered a trial off of medication to determine whether medication is still necessary.

2. Ch i ldren with ADHD may require changes in the i r educational programming. Combination therapy with medications and behavior/psychological therapy is superior to behavior/psychological therapy alone and necessary for restoration of function and inclusion.

COMBINATION THERAPY

1. Combination therapy uses both behavioral interventions and medications.

2. Combination therapy may be warranted in preschool children who do not respond to behavioral interventions.

3. In a systematic review and a meta-analysis, combination therapy with medications and behavior/psychological therapy was superior to behavior/psychological therapy alone.

4. Children receiving combined treatment may require lower doses of medication and achieve greater improvement in non-ADHD symptoms (e.g. oppositional/aggressive, internalizing, teacher-rated social skills, parent-child relations, and reading achievement) than children receiving medication alone.

COMBINATION THERAPY

5. Cognitive behavioral therapy may be a helpful adjunct to medications for adolescents with ADHD.

6. Dietary interventions are not recommended.

WHEN TO REFER TO A DEVELOPMENTAL PEDIATRICIAN,

CHILD NEUROLOGIST, CHILD PSYCIATRIST

1. Co morbid conditions (e.g. oppositional defiant disorder,

conduct disorder, substance abuse, emotional problems)

2. Coexisting neurologic, or medical conditions

(e.g. seizures, tics, autism spectrum disorder, sleep disorder)

3. Lack of response to a controlled trial of stimulant or non

stimulant therapy.

DISABILITY CERTIFICATION

• Currently, Indian Government organizations and the Persons

with Disability Act (Equal Opportunities, Protection of Rights

and Full Participation), 1995, the National Trust, CCPD Office

do not recognize Attention Deficit Hyperactive Disorder as a

neuro- developmental disorder.

• There are no provisions for ADHD.