Diagnosis and Management of ADHD in Children

Slide 1: The article I will be talking about today is called Diagnosis and Management of ADHD in Children. This article is based on the University of Michigan Health System guideline for ADHD and includes other guidelines and reviews.

Introduction:Most common behavioral disorder: Recent national data show that up to 11% of four- to 17-year-olds have had an ADHD diagnosis, 8.8% currently have the diagnosis, and 6.1% are receiving a medication for ADHD.

Etiology is not fully understood yet it is known that genetic and neurologic factors play a role. 1. Genetic: ADHD is two to eight times more common in people who have a first degree relative with the condition2. Neurologic: ADHD is associated with deficits in brain structure and neuronal functioning and connectivity.

Evaluation (general):To evaluate a child with possible ADHD, there are certain steps that you can follow to help you be better organized.

Presentation: child between the ages of 4 and 12 years, presenting with inattention, hyperactivity, impulsivity, poor academic performance or behavioral problems at school or at home.

Evaluation (post DSM V):Once you have the diagnostic criteria in mind these would guide your history taking Parent or caretakers report of symptoms for ADHD and other disorders in home setting School or community report of symptoms outside the home Patients point of view (older children and adolescents) Behavioral rating scales: Many exist. Free one is by the American Academy of Pediatrics. National Initiative for Childrens Healthcare Quality Vanderbilt Assessment ScaleIt is for ages 6 to 12 years. It includes parent form, teacher form and scoring instructions. Others for different ages are present but those have to be purchased. Some include a self-report form.

Attention:But while doing all that, there is something that we forgot to pay attention to. No its not that youre boring, its just that there are a number of conditions that may mimic or coexist with ADHD. In fact, 1/3 of individuals with ADHD have a comorbid diagnosis

A Couple of Tips: Usually in preschoolers, validated behavioral rating scales can improve diagnostic confidence

Which subtype has a delayed presentation? (Inattentive subtype: when academic requirements become greater)Patients should be assessed for sleeping problems at this age esp OSA

Above age of 12: maybe if subtle symptoms were present at an earlier ageIn this age group pay attention to learning disabilities, mental health conditions, sleep problems and substance abuse.

Treatment:1. Treatment of children younger than 6 years of age should begin with behavioral therapy.2. Treatment of children six years and older should begin with medications.

The Multimodal Treatment Study of Children with ADHD assessed treatment effects in 579 children seven to nine years of age. Patient received behavioral therapy, medication, and combined behavioral therapy and medication over 14 months Similar benefits (behavior, social skills, relationships and academics) were observed in children who received medication alone compared to those who received medication and behavioral therapy

Behavioral Treatment: Positive parenting strategies such as praise and rewards for targeted behaviors

Medication Treatment:1. Most effective and safe option and are the first choice for ADHD treatment in national guidelines and reviews2. Are also effective but have fewer supporting studies and are less effective than psychostimulantsOthers such as antidepressants or mood stabilizers used off-label cause not FDA approved for treating ADHD

Psychostimulants:Benefit: Children with ADHD who are taking a stimulant are less likely to be held back a grade + may improve driving performanceAdverse effects: Start with a low dose and increase it once to twice weekly depending on feedbackSuicide: Rare but family members should be informed about the riskCardiac problems: Evidence is conflicting but national guidelines recommend that physicians consider echocardio and/or cardiology referral in patients with history of palpitaions, syncope, or family history of sudden cardiac death or long QT syndrome among others.

Monitoring:Follow up visits should check on weight, height, heart rate, blood pressure, ADHD symptoms, moor and treatment adherence. Medication holidays in case of adverse effects (decreased growth velocity)