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ImplementingtheKeyActionStatementsAnAlgorithmandExplanationforProcesso ImplementingtheKeyActionStatementsAnAlgorithmandExplanationforProcesso

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4to 18yold patient identified with signs or symptoms suggesting ADHD Symptoms can come from parents direct concerns or the mental health screen recommended by the TFOMHSee TFOMH Algorithms Manypare ID: 899431

adhd adolescent cit child adolescent adhd child cit family ons management tion etal concerns behavior adoles hyperactivitydisorder school developmental

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1 ImplementingtheKeyActionStatements:AnAlg
ImplementingtheKeyActionStatements:AnAlgorithmandExplanationforProcessofCarefortheEvaluation,Diagnosis,Treatment,andMonitoringofADHDinChildrenandAdolescentsPracticeguidelinesprovideabroadoutlineoftherequirementsforhigh-qualityevidence-basedcare.Insup-portofconsistentandcomprehensivecareforchildrenandadolescentswithsymptomsofattentionandhyperactiv-itydisorderswithinatypical,busype-diatricpractice,theAAPhasdevelopedthefollowingsuggestedprocess-of-carealgorithm(seeSupplementalFig 4-to 18-y-old patient identified with signs or symptoms suggesting ADHD. Symptoms can come from parents’ direct concerns or the mental health screen recommended by the TFOMHSee TFOMH Algorithms Manyparentsbringtheirchild/adoles-centtotheprimarycareclinicianwithspeci“cconcernsaboutthechilds/ad-olescentsabilitytosustainattention,curbactivitylevel,and/orinhibitim-pulsivity.Inthesecases,itisclearthattheclinicianshouldinitiateanevalua-tionforADHD.However,inmanyin-stances,thechiefconcernmightin-cludebehaviorsandcharacteristicsassociatedwithADHDwithoutmentionofthecoreADHDsymptoms.Forexam-ple,children/adolescentsmighthavedif“cultyremainingorganized,plan-ningactivities,orinhibitingtheirinitial Assess impact on treatment planFurther evaluation/referral as needed Exit this guideline.Evaluate or refer, as appropriate.Idenfy the child as CYSHCN if appropriate. Inattention and/or hyperactivity/impulsivity problems not rising to DSM-IV diagnosisProvide educaon of family and child re: concerns (eg, triggers for inaenon or hyperacvity) and behavior management strategies or school-based strategies Enhanced Coexisting disorders preclude primary care management? Follow-up and establish co-management planSee TFOMH Algorithms 4-to 18-y-old patient identified with signs or symptoms suggesting ADHD. Symptoms can come from parents’ direct concerns or the mental health screen recommended by the TFOMHSee TFOMH Algorithms See action statement 1Yes 24675Overview of the A See action statement 3 Provide educaon to family and child re: concerns (eg, triggers for inaenon or hyperacvity) and behavior-management strategies or school-based strategies Provide educaon addressing concern (eg, expectaons for aenon as a funcon of age)Enhanced SurveillanceYes diagnosis of Legend = Start= Continued care= Decision= Action/process Opon: Medicaon(ADHD only and past medical or family history of cardiovascular disease considered) Iniate treatment Titrate to maximum bene“t, minimum adverse eects Monitor target outcomes Opon: Behavior management (developmental variaon, problem or ADHD) Idenfy service or approach Monitor target outcomes Opon: Collaborate with school to enhance supports and services (developmental variaon, problem, or ADHD) Idenfy changes Monitor target outcomesSee action statement 5See action statement 6BEGIN TREATMENT Coexisting conditions? symptoms improve? Reevaluate to confirm diagnosis and/or provide education to improve adherence.Reconsider treatment plan including changing of the medication or dose, adding a medication approved for adjuvant therapy, and/or changing behavioral therapy.Yes chronic care management at least 2x/year for ADHD issues 3 Perform Diagnostic Evaluation for ADHD and Evaluate or Screen for Other/Coexisting Conditions: Family(parents, guardian, other frequent caregivers): Chief concerns History of symptoms (eg, age of onset and course over me) Family history Past medical history Psychosocial history Review of systems Validated ADHD instrument Evaluaon of coexisng condions Report of funcon, both strengths and weaknesses School (and important community informants): Concerns Validated ADHD instrument Evaluaon of coexisng condions Report on how well paents funcon in academic, work, and social interacons Academic records (eg, report cards, standardized tesng, psychoeducaonal evaluaons) Administrave reports (eg, disciplinary acons) Child/adolescent (as appropriate for childs age and developmental status): Interview, including concerns regarding behavior,

2 family relaonships, peers, school For a
family relaonships, peers, school For adolescents: validated self-report instrument of ADHD and coexisng condions Report of childs self-iden“ed impression of funcon, both strengths and weaknesses Clinicians observaons of childs behavior Physical and neurologic examinaonSee action statements 2–3 Yes Apparently typical or developmental Yes ESTABLISH MANAGEMENT TEAM Identify child as CYSHCN Establish team including coordination plan Collaborate with family, school, and child to goals.See action statement 4 SUPPLEMENTALAPPENDIXFIGURE2ADHDprocess-of-carealgorithm.TFOMHindicatesTaskForceonMentalHealth;CYSHCN,child/youthwithspecialhealthcareneeds.FROMTHEAMERICANACADEMYOFPEDIATRICS initiatingthediagnosticevaluationmightbeappropriate.PerformDiagnosticEvaluationforADHDandEvaluateorScreenforCoexistingDisordersIdeally,theprimarycareof“cestaffcanasktheassistanceoftheparent(s)inobtaininginformationonthepur-poseofavisitatthetimeofscheduling.Ifpossible,anextendedvisitisoftendesirablefortheevaluationofADHD.Asageneralapproachtotheinitialevaluation,dataonthechilds/adoles-centssymptomsandfunctioning(eg,homeorschoolquestionnaires)shouldbegatheredfromparents,schoolpersonnel,andothersources,preferablybeforethevisit.Thisstrat-egyallowstheprimarycarepediatri-ciantofocusonpertinentissuesforthatchild/adolescentandfamilyatthetimeofthevisit.Parentalconsenttoauthorizethereleaseofschooldatatopediatricprovidersisimportanttoob-tain.Theprocessmightbefacilitatedifthefamilyisgiventheresponsibilitytoprovideotherinformantswiththequestionnairesordata-collectionformstobeusedandtorequestotherrecordsandreports.TomakeadiagnosisofADHD,theclini-cianneedstoestablishthatatleast6ormorecoresymptomsperdimen-sionpresentedinSupplementalTablearepresentineitherorbothofthedimensionsofinattentionand/orDiagnosticcriteriaforADHDinschool-agedchildrenandadolescentsincludedocumentationofthefollowingcrite-Atleast6ofthe9behaviorsde-scribedintheinattentivedomainandtoadegreeincon-sistentwiththechildsdevelopmen-talage,and/orAtleast6ofthe9behaviorsde-scribedinthehyperactive/impul-sivedomainoccurandtoade-greeinconsistentwiththechildsdevelopmentalage.Presenceofsomeimpairmentin2ormoremajorsettings(eg,homeandschool)foratleast6months.PresenceofsomesymptomsofADHDthatcausedimpairment(ac-cordingtothehistory)before7yearsofage.Symptomshavepersistedforatleast6months.Evidenceofsigni“cantclinicalim-pairmentinsocial,academic,oroc-cupationalfunctioningbecauseofthebehaviors.Symptomsarenotattributabletoanotherphysical,situational,ormentalhealthcondition.criteriade“ne3subtypesofADHD:ADHDprimarilyoftheinattentivetype(ADHD/I,havingtheinappropri-atelyoftenoccurrenceofatleast6of9inattentionbehaviorsandhyperactive-impulsivebehaviors);ADHDprimarilyofthehyperactive-impulsivetype(ADHD/HI,havingtheinappropriatelyoftenoccurrenceofatleast6of9hyperactive-impulsivebehaviorsand6inattentionbe-haviors);andADHDcombinedtype(ADHD/C,hav- Perform Diagnostic Evaluation for ADHD and Evaluate or Screen for Other/Coexisting Conditions: Family(parents, guardian, other frequent caregivers): Chief concerns History of symptoms (eg, age of onset and course over me) Family history Past medical history Psychosocial history Review of systems Validated ADHD instrument Evaluaon of coexisng condions Report of funcon, both strengths and weaknesses (and important community informants): Concerns Validated ADHD instrument Evaluaon of coexisng condions Report on how well paents funcon in academic, work, and social interacons Academic records (eg, report cards, standardized tesng, psychoeducaonal evaluaons) Administrave reports (eg, disciplinary acons) Child/adolescent (as appropriate for childs age and developmental status): Interview, including concerns regarding behavior, family relaonships, peers, school For adolescents: validated self-report instrument of ADHD and coexisng condions Report of childs self-iden“ed impression of funcon, both strengths and weaknesses Clinicians observaons of childs behavior Physical and neurologic examinaonSee acti

3 on statements 2–3 SUPPLEMENTALTABLE2Core
on statements 2–3 SUPPLEMENTALTABLE2CoreSymptomsofADHD(AdaptedFromtheDSM-IV-TR) InattentionDimensionHyperactivity-ImpulsivityDimensionHyperactivityImpulsivityCarelessmistakesFidgetyBlurtsanswersbeforequestionsarecompletedDif“cultysustainingattentionUnabletostayseatedDif“cultyawaitingturnSeemsnottolistenMovesexcessively(restless)Interrupts/intrudesonothersFailsto“nishtasksDif“cultyengaginginleisureactivitiesquietlyDif“cultyorganizingOnthegoŽTalksexcessivelyAvoidstasksthatrequiresustainedattentionLosesthingsEasilydistractedSupplementalAppendixPEDIATRICSVolume,Number, ingtheinappropriatelyoftenoccur-renceofatleast6of9behaviorsinboththeinattentionandhyperactive-impulsivedimensions).Thereisalsoevidencethatthecriteriaareappropriateforpreschool-agedandadolescents.Theuseofspeci“cDSM-IV-TRcriteriadecreasesvariationamongcliniciansinhowthediagnosisismadeandwillfacilitatecommunicationamongprofessionalsandpatients.DSM-IV-TRcriteriarequireevidenceofimpairingsymptomsbefore7yearsofage.Insomecases,thesymptomsofADHDmightnotberecognizedbypar-entsorteachersuntilthechildisolderthan7years,whenschooltasksbe-comemorechallenging.Inchildrenforwhomtheproblemsareidenti“edaf-ter7yearsofage,historycanoftenidentifyanearlierageofonsetofsomeofthesymptoms.Delayedrecognitionmightbeseenmoreoftenintheinat-tentivesubtypeofADHD.Ifsymptomsarisesuddenly,withoutprevioushistory,primarycareclini-ciansshouldconsiderothercondi-tionsincludingheadtrauma,physicalorsexualabuse,neurodegenerativedisorders,moodoranxietydisorders,substanceabuse,oramajorpsycho-logicalstressinthefamilyorschool.Therequirementsthatachildmusthavesigni“cantimpairmentinfunc-tionandsomeimpairmentinatleast2settingsarethemostchallengingas-pectsoftheDSM-IV-TRcriteriaforthecliniciantoobtainaccurateinforma-tion.Thepresenceoffunctionalim-pairmentsisoftenthemosttroublingissueforchildren,families,andteach-ersandisacentralrequirementinmakingthediagnosisofADHDseeBehaviorManagementŽ).Aswasdeterminedinthepreviousguideline,parentandteacherratingscalesthatuseDSM-IV-TRcriteriaforADHDarehelpfulinobtainingtheinfor-mationrequiredtomakeadiagnosisonthebasisoftheDSM-IV-TRcriteria.Broad-bandratingscalesthatassessmentalhealthfunctioningingeneraldonotprovidereliableandvalidindi-cationsofADHDdiagnosesbutmighthelpinscreeningforco-occurringbe-havioralconditions.Nocurrentinstrumentsroutinelyusedinprimarycarepracticereliablyas-sessthenatureordegreeoffunctionalimpairmentinchildrenwithADHD,al-thoughparent-reportinstrumentsmighthelp.Somemeasuresthatareavailablearelimited,becausetheymostlyprovideonlyaglobalrating(eg,theStrengthsandDif“cultiesQues-tionnaire[SDQ]ImpactScaleandtheChildrensGlobalAssessmentScaleScale9)orhavemorelimitedvalida-tion(eg,theperformancecomponentoftheVanderbiltScales).Reviewofdocuments,suchasreportcardsandresultsofstandardizedtesting,andev-idenceofdetention,suspensions,orexpulsionsfromschoolcanalsoserveasevidenceoffunctionalimpairment.Withinformationobtainedfromtheparentandschool,theclinicianwillneedtomakeaclinicaljudgmentabouttheeffectofthecoreandasso-ciatedsymptomsofADHDonacademicachievement,classroomperformance,familyandsocialrelationships,inde-pendentfunctioningandsafety/acci-dentalinjuries,self-perception,leisureactivities,andself-care(suchasbath-ing,toileting,dressing,andeating).Ad-ditionalguidanceregardingfunctionalassessmentisavailablethroughtheAAPADHDtoolkitandtheTaskForceonMentalHealth.Intheabsenceofotherconcernsand“ndingsonmedicalhistory,familyandsocialhistory,andphysicalexamina-tionofthechild,nofurtherdiagnostictestingwillhelptoreachthediagnosis.Comparedwithclinicalinterviews,standardizedpsychologicaltests,suchascomputerizedtestsofattention,havenotbeenfoundtoreliablydiffer-entiatebetweenyouthwithandwith-outADHD.Appropriatefurtheras-sessmentisindicatedifanunderlyingetiologyissuspected.Assessmentssuchasscreeningforhighleadlevels,lowironorferritinlevelsorabnormalthyroidhormonelevelsorimagingstudiesshouldbepursuedonlyifotherhistoricorphysicalinformationsug-geststheirpresence.Conditionssuchassleepdisorders,suchasapnea,ab-senceseizures,hyperthyr

4 oidism,ormoodoranxietydisordersmightpres
oidism,ormoodoranxietydisordersmightpres-entwithADHDsymptomsandmightberelievedwhentheprimaryconditionisCurrentcriteriadonotdescribegen-derordevelopmentaldifferences,al-thoughnumerousstudieshavefoundthatthefrequencyofsymptomaticbe-haviorsvariessigni“cantlyacrossgenderandagegroups(forareview,seeBarkley).Comparedwithothergirls,girlswithADHDexperiencemoredepression,anxiety,distress,poorteacherrelationships,stress,externallocusofcontrol,andimpairedaca-demics.ComparedwithboyswithADHD,girlswithADHDexperiencemoreimpairmentinself-reportedanx-iety,distress,depression,andexternallocusofcontrol.Furthermore,thebe-havioralcharacteristicsspeci“edintheDSM-IV-TR,despiteeffortstostan-dardizethem,remainsubjective,toagreatextent,andmaybeinterpreteddifferentlybydifferentobservers.Cul-turalnormsandexpectationsofpar-entsorteachersmayin”uencetheperspectivesofvariousinformants.TheratesofADHDanditstreatmenthavebeenfoundtobedifferentfordifferentracial/ethnicgroups.clinicianmustremainsensitivetocul-turaldifferencesintheappropriate-nessofbehaviorsandperceptionsofmentalhealthconditions.Otherfac-tors,suchaspovertyandaccesstocare,likelycontributetotheculturalFROMTHEAMERICANACADEMYOFPEDIATRICS differences.ThesecomplexitiesinthediagnosismeanthatclinicianswhouseDSM-IV-TRcriteriamustapplytheminthecontextofsoundclinicalTheDSM-IV-TRdoesincludeacategoryofADHDnototherwisespeci“ed.ŽThiscategoryismeantforchildrenwhomeetmanybutnotthefullcriteriaforADHD,suchaschildrenwhomeetallthesymptomandimpairmentcriteriabutwhoseageofonsetislaterthan7yearsorchildrenwhohaveclinicallysigni“cantimpairmentbutdonotmeetallthesymptomrequirements.Clinicallysigni“cantimpairmentisre-quiredindiagnosingachildwithADHD.Childrenwithinattentiveorhyperac-tive/impulsivesymptomsbutlessthansigni“cantimpairmentarecharacter-izedashavingproblems.ŽAcomprehensivediagnosticevalua-tiontypicallybeginswithidentifyingfamilyschiefconcerns.Theclini-cianalsoneedstohavethefamilymemberscompleteavalidatedADHD.Familymembersshouldbeaskedtoprovideahistoryofsignsandsymptoms.Thishistoryincludesdeterminingtheonset,frequency,anddurationofproblembehaviors,situa-tionsinwhichtheyincreaseorde-crease,previoustreatmentsandtheirresults,andthefamilysunderstand-ingoftheissues.Thefamilyhistoryshouldincludeanymedicalsyn-dromes,developmentaldelays,cogni-tivelimitations,learningdisorders,ormentalillnessinfamilymembers,in-cludingADHDandmood,anxiety,andbipolardisorders.Inaddition,parentaltobaccoandsubstanceuseisrelevanttoriskfactorsforADHD.Familymem-bersmightnothavebeenformallydi-agnosedwithADHD;askingaboutfam-ilymembersschoolexperienceandproblemssimilartothoseofthepa-tientmightsuggestundiagnosedcasesofADHD.Updatingthemedicalhistorycanfo-cusonfactorsassociatedwithADHD,suchaspretermdelivery,neonatalproblems,congenitalinfections,andheadtrauma.Thepsychosocialhis-shouldincludeenvironmentalfac-tors,suchasfamilystressandprob-lematicrelationshipsthatmightcontributetothechilds/adolescentsoverallfunctioning.Itisimportanttoobtainhistoryofcon-ditionsthatmightmimicADHDsymp-tomsormightco-occurwiththecondi-tion.Co-occurringconditionsarediscussedlaterintheprocessalgo-rithm.Severalavailablequestion-nairesalsoprovideascreenforcoex-istingconditionsandareportof.Itisimportanttoobtainahistorythatwouldsuggestleadexpo-sure,absenceseizures,orothermen-talillnessessuchasanxietyormooddisordersandTourettedisorder.Afullreviewofsystemsmightalsorevealothersymptoms,suchassleepdistur-bances,thatmayassistinformulatingadifferentialdiagnosisand/ormaybeconsideredinthedevelopmentofman-agementplans.Thepatientshouldalsobescreenedforhearingand/orvisualPrimarysleepdisorders,suchasob-structivesleepapneasyndromeandrestless-legsyndrome/periodiclimb-movementdisorder,mightpresentwithsymptomsofinattention,hyper-activity,andimpulsivityorarefre-quentlyassociatedwithADHD.childrenbeingevaluatedforADHDshouldbesystematicallyscreenedforsymptomsof(ie,frequentsnoring,ob-servedbreathingpauses;restlesssleep,urgetomovetheirlegsatnight;daytimesleepiness)andriskfactorsfor(ie,adenotonsillarhypertrophy,asthma/allergies,obesity;familyh

5 is-toryofrestless-legsyndrome/periodicli
is-toryofrestless-legsyndrome/periodiclimb-movementdisorder,ironde“-ciency)primarysleepdisorders.Sleep-assessmentmeasuresthathavebeenshowntobeusefulinthepediat-ricprimarycarepracticesettingin-cludebriefscreeningtoolsparent-reportsurveys.polysomnographyshouldbestronglyconsideredforchildrenwithsymp-tomssuggestiveofand/orriskfactorsforobstructivesleepapneasyndromeandrestless-legsyndrome/periodiclimb-movementdisorder.Inaddition,evenintheabsenceofpri-marysleepdisorders,modestreduc-tionsinsleepduration,suchasthoseassociatedwithenvironmentallyre-latedinsuf“cientsleep,mightbeasso-ciatedwithdetectabledeteriorationinvigilanceandattentioninchildrenwithADHDandshouldbeevaluatedandad-Commonclinicalpresenta-tionsofinsomniainchildrenwithADHDincludebedtimeresistance,de-layedsleeponset,nightwakings,andearly-morningawakening.Bothabase-lineassessment(ie,beforeinitiatingtreatment)andongoingperiodicscreeningforsleepproblemsshouldbeincludedinthemanagementofallchildrenwithADHD.Sleepdiariesareusefuladjunctsinquantifyingsleep-onsetlatencyandnightwakingsandassessingvariabilityinsleeppat-Thedifferentialdiagnosisofin-somniainchildrenwithADHDincludes:ADHDmedication(stimulantandnonstimulant)effects:Directeffectsonsleeparchitec-ture(ie,prolongedsleep-onsetla-tencyanddecreasedsleepdura-tion,increasednightwakings);andIndirecteffectssuchasinade-quatecontrolofADHDsymptomsintheeveningandmedicationwithdrawalorreboundSleepproblemsassociatedwithco-existingpsychiatricconditions(ie,SupplementalAppendixPEDIATRICSVolume,Number, anxietyandmooddisorders,disrup-tivebehaviordisorders).Circadian-basedphasedelayinsleep-wakepatterns,whichhavebeenshowntooccurinsomechil-drenwithADHD,whichresultsinbothprolongedsleeponsetanddif-“cultywakinginthemorning.Inadequatesleephygiene(ie,incon-sistentbedtimesandwaketimes,absenceofabedtimeroutine,elec-tronicsinthebedroom,caffeineIntrinsicde“citassociatedwithADHD.NumerousstudieshavefoundthatnonmedicatedchildrenwithADHDandnocomorbidmoodoranx-ietydisordershavesigni“cantlygreaterbedtimeresistance,moresleep-onsetdif“culties,andmorefrequentnightawakeningswhencomparedwithtypicallydevelopingcontrolchildren.Inaddition,somechildrenwithADHDseemtohaveev-idenceofincreaseddaytimesleepi-nessevenintheabsenceofapri-marysleepdisorder.Asoundassessmentoffunctioninginmajorareascanthenbeusedtocon-structaneducationalandbehavioralpro“leincludingnotonlyconcernsbutalsostrengthsortalents.ThemostcommonareasoffunctioningaffectedbyADHDincludeacademicachieve-ment;peer,parent,sibling,andadultauthority-“gurerelationships;partici-pationinrecreationsuchassports;andbehaviorandemotionalregula-tion,includingriskybehavior.Onesys-tematicapproachtotheassessmentoffunctioncanusetheframeworkoftheInternationalClassi“cationofFunc-tioning,Disability,andHealth.Suggestionsandrecommendationsforscalessuchasthemodi“edPatientHealthQuestionnaire-9Modi“edforAdolescents(PHQ-A)andScreenforChildAnxietyRelatedEmotionalDisor-ders(SCARED)havebeendevelopedbytheAAPTaskForceonMentalThesituationmightbemorecomplicatedwhenparentsdisagree,particularlyindivorcesituationswhenparentswithsharedcustodyperceivethechildsproblemsandstrengthsdif-ferently.Undersuchcircumstances,theclinicianmustusecommunicationskillsto“ndaconsensusonthediag-nosisandplan.Elicitinginformationfromextendedfamilymembersmighthelpclarifysomeofthedifferences.SCHOOLAND/OROTHERCOMMUNITYINFORMANTSMultipleinformantsarerequiredforclinicianstodeterminethenatureandseverityofsymptoms,impactofthesymptomsonfunctionin2ormoresettings,andwhetherthechild/adolescentmeetsDSM-IV-TRcriteriaforthediagnosisofADHD.Inmostcases,theteacherprovidesthosereports.Thereportsofparentsandteachersareoftensuf“cientfortheADHDdiagnosis,butinformationfromthepatientisessentialforiden-tifyingtheinternalizingconditionsofmoodandanxietydisorders.RatingscalesrecommendedbytheTaskForceonMentalHealthmaybehelp-ful.Insomecircumstances,itmightbedesirabletosolicitinformationfromadditionalsources.Schoolre-ports,forexample,mightbemoredif“culttoobtain„orlesscompre-hensive„incasesthatinvolvepreschool-agedchildrenandadoles-cents.Othe

6 radultswhoareactiveinthelifeofanadolesce
radultswhoareactiveinthelifeofanadolescent,suchascoaches,pastors,orscoutleaders,canbeaskedtocompleteratingscalestodevelopafullpro“leoftheadolescent,althoughtheaccuracyoftheirreportinghasnotbeenstudiedTeachersmightindicatetheirmajorbyusingquestionnairesorverbalinputbytelephoneorthroughdirectconversation.Anap-propriateschoolrepresentativeshouldbeaskedtocompleteadatedADHDinstrumentorbehav-iorscalebasedonDSM-IV-TRcriteriaforADHDandprovideobservationsthatmightsuggestcoexistingoral-ternativeconditions,includingdis-ruptivebehaviordisorders,depres-sionandanxietydisorders,tics,orlearningdisabilities.Reportof,bothstrengthsandweak-nesses,mightbegleanedbyques-tionnairesoracademicrecordsthatcanincludereportcards;stan-dardizedtestinginreading,mathe-matics,andwrittenexpression;vali-datedfunctionalassessmenttoolsmentionedpreviously;andprevi-ouspsychoeducationalevaluations.Theserecordscanhelpestablishachilds/adolescentspro“leofaca-demicandbehavioralperformanceinschool,thepresenceofalearningdisability,dif“cultyinfollowingschoolrules,thequalityofpeerin-teractions,andtheextentofschoolIftherecordsindicatethatthechildishavingdif“cultylearningaca-demicskills,thephysicianshouldde-termineifthechildhasbeenas-sessedforapotentiallearningproblembytheschool,becausethereisahighcomorbiditybetweenlearningdisabilitiesandADHD.Theschoolassessmentmightusearesponse-to-interventionmodelaspartofthediagnosticprocessinwhichlearningproblemsareevalu-atedonthebasisofthechildsre-sponsetoevidence-basedacademicinterventions,oramultidisciplinaryteamevaluationmightbeconductedbytheschool.IfthechildhasanIndi-vidualizedEducationProgram,thisdocumentshouldbereviewedbytheIfthechildcontinuestostrugglede-spitetheschoolsinterventionsandtreatmentforADHD,furtherpsychoe-ducationalorneuropsychologicalas-FROMTHEAMERICANACADEMYOFPEDIATRICS sessmentisnecessary.Theclinicianmightwanttorecommendthattheevaluationsbeperformedbyaninde-pendentpsychologistorneuropsy-chologist.Despitetheimportanceofthepsychologicalassessments,in-surancecoverageisquitevariable,andfamiliesshouldbeencouragedtoinvestigatetheircoveragewhenpursuingindependentpsychologicalevaluations.Financingcommunity-basedevaluationshasbeenad-dressedinapreviousAAPstate-ChildrenwithintellectualorotherdevelopmentaldisabilitiesmightalsohaveADHD,buttheas-sessmentinthesecasesismorecomplicated,becauseonemusten-surethattheacademicexpectationsarematchedtothechildsacademicabilitiesandthelevelofADHDsymp-tomsexceedswhatwouldbeex-pectedforachildsdevelopmentallevel.Primarycarephysiciansin-volvedinassessingADHDinchildrenwithintellectualdisabilitieswillneedtocollaboratecloselywithaschoolpsychologistorindependentInadditiontotheacademicinforma-tion,informationshouldbere-questedthatcharacterizesthechilds/adolescentsleveloffunc-tioningwithregardstopeer,teacher,andotherauthority“gurerelationships;abilitytofollowdirec-tions;organizationalskills;historyofclassroomdisruption;andassign-mentcompletion.ofdisciplinaryaction,suchassuspensionsandexpulsions,anddescriptionsofbehavioratschoolre”ectsocialfunctionandbehav-ioralregulationandsuggestthepos-sibilityofcoexistingconditions.Foradolescentswhohavemultipleteachers,itisdesirabletoobtainbe-haviorandimpairmentratingsfromatleast2teachersinacademicsubjects(eg,mathandEnglishteachersor,forchildren/adolescentswithlearningdisabilities,ateacherintheareaofstrongfunctionandateacherintheareaofweakfunction).TheADHDtool-providesmaterialsrelevanttothisschooldatacollection.Teacherandparentreportsfrequentlyandtherealsomightbedis-agreementbetweenparents.Theseob-servationsmightnotbeinaccurate,becauseparentsandteachersob-servethechildrenunderdifferentcir-cumstances.Whenthereisdisagree-ment,itishelpfultoobtainmoreinformationsuchasthecircumstanceunderwhichtheindividualsobservedthechild,thedemandsonthechildduringthoseobservations,theobserv-ersunderstandingofthebehaviorsandhowtodealwiththem,andtheob-serversunderstandingofADHDandhowitistreatedaswellastheroletheyplaywiththechild.Asnotedpre-viously,obtaininginformationfromad-ditionalsources,suchasgrandpar-ents,coaches,or

7 Sundayschoolteachers,canbehelpful.Thecli
Sundayschoolteachers,canbehelpful.Theclini-ciansdecisionaboutthediagnosisisaclinicaljudgmentmadeonthebasisofalltheinformationthatisavailable.Theclinicianshouldconductanage-,includingthechilds/adolescentsconcernregardinghisorherownbehavior,andregardingfamilyrelationships,peers,andschool.Itisimportanttoincludeadiscussionofhisorherstrengths,goals,anddif“cul-ties.Alongwiththeinterview,theuseofanappropriatevalidatedself-reportinstrumentofADHDandco-existing,primarilyforadolescents,canaidintheassessmentofriskofADHDandanxietyandmooddisorders.Itisalsoimportanttoaskaboutdelusionalthinkingandsuicidalthoughtsorac-tions.Thisevaluationshouldalsopro-videabaselineofthechilds/adoles-centsself-identi“edreportoffunctionathome,inschool,atwork,andamongpeersaswellasvalidatedfunctionalas-sessmenttools.Wheneverpossible,theindividualchildsoryouthsownviewofwhatheorshewouldliketoseechangedshouldbeconsideredprimarytargetsforintervention,becausethesegoalsmightattimesdifferwidelyfromparentorschoolconcerns.Theclinicianmustkeepinmindthetendencyofmanychildren/adoles-centstounderreporttheirADHDandotherdisruptivebehaviorsymptoms.However,thebaselineimpressionsofthechild/adolescentcanthenbeusedasthebasisforshapingthepatientsunderstandingofADHDandcoexistingsymptomsaswellasmonitoringfunc-tioninsocial,behavioral,andaca-demicdomains.Activeinvolvementofthechildren/adolescentsmightbeusefultoempowerthemtounder-standandparticipateintheirowndi-agnosticformulationand,later,toob-tainbuyinŽtotheirtreatmentplanandimproveadherencetotreatment.RecommendationsoftheAAPTaskForceonMentalHealthandtheGuide-linesforAdolescentDepressioninPri-maryCare(GLAD-PC)includeusingvalidateddiagnosticratingscalesforadolescentmoodandanxietydisor-dersforclinicianswhowishtousethisformat.Inaddition,theCRAFFT(car,re-lax,alone,forget,friends,trouble)isanavailablescreenforsubstanceofthepatientshouldberecordedandincludehisorherlevelofattention,activity,andim-pulsivityduringtheencounter.Anim-portantcaveatisthatthe“ndingsseeninothersettings,includingcoresymp-toms,areoftennotobservedduringof“cevisits.Specialattentionshouldbepaidtolan-guageskillsinpreschool-agedandyoungschool-agedchildren,becausedif“cultieswithlanguagecanbeasymptomofalanguagedisorderandSupplementalAppendixPEDIATRICSVolume,Number, predictorofsubsequentreadingprob-lems;suchlanguagedisordersmightpresentasproblemswithattentionandimpulsivity.Likewise,socialinter-actionsshouldbenotedduringtheex-amination,becausetheyareanotherpossibleareaofde“ciency.physicalandneurologicexami-mustbecomprehensive.Aphysicalandneurologicexaminationshouldbeconductedtodetermineiffurthermedicalordevelopmentalas-sessmentsareindicated.Baselineheight,weight,bloodpressure,andpulsemeasurementsshouldbetaken.Amongthesignstonotearehearingandvisualacuityandcardiovascularstatus.Dysmorphicfeaturesshouldalsobenoted,becauseADHDmightbeassociatedwithgeneticsyndromes(eg,fetalalcoholsyndromeandfragileX).Theneurologicevaluationshouldincludedevelopmentalandmentalsta-tusobservationsincludingaffect;com-municationskills,includingspeechandlanguage;tics;andgrossand“nemotorcoordination.ManychildrenwithADHDwillhavepoorcoordination,whichmightbesevereenoughtowar-rantadiagnosisofdevelopmentalco-ordinationdisorder.The“ndingscanaffecthowwellthechildcanperformincompetitivesportsandcanalsoad-verselyaffecthisorherwritingskills.Throughhistoryandexaminationofthechilds“neandgrossmotorskills,thecliniciancanidentifythesede“citsandaddresstheminthemanagement diagnosis of Asaresultofthediagnosticevalua-tion,aprimarycareclinicianshouldbeabletoanswerthefollowingques-Howmanyinattentiveandhyperac-tive/impulsivebehaviorcriteriaforADHDdoesthechild/adolescentmeetacrossthemajorsettingsofhisorherlife?Havethesecriteriabeenpresentfor6monthsorlonger?Wastheonsetoftheseorsimilarbehaviorspresentbeforetheageof7years?Whatfunctionalimpairments,ifany,arecausedbythesebehaviors?Couldanyotherconditionbeabet-terexplanationforthebehaviors?Isthereevidenceofcoexistingprob-lemsordisorders?Onthebasisofthisinformation,theclinicianshouldbeabletoarriveatapreliminarydiagno

8 sis.OTHERDISORDERSIfsymptomsarisesuddenl
sis.OTHERDISORDERSIfsymptomsarisesuddenly,with-outanyprevioushistory,primarycarecliniciansshouldconsiderotherconditions,includingheadtrauma,physicalorsexualabuse,neurodegenerativedisorders,moodandanxietydisorders,sub-stanceabuse,oramajorpsycho-logicalstressinthefamilyorinschool,suchasbullying. Exit this guideline.Evaluate or refer, as appropriate.appropriate.Idenfy the child as CYSHCN if Yes Iftheevaluationidenti“esorsug-geststhatanotherdisorderisthecauseoftheconcerningsignsandsymptoms,thenitisappropriatetoexitthisalgorithm.Theapproachinthatcaseisdictatedbytheresultsoftheevaluation.Ifareferralismade,theprimarycareclinicianshouldframethereferralquestionsclearlyandexpectthesereferralquestionstobeansweredinamannerthatwillensurethatacomanagementplanthataddressesthefamiliesandchilds/adolescentsongoingneedsforeducationandgeneralandspe-cialtyhealthcareisestablished.Re-sourcesfromtheAAPTaskForceonMentalHealthmightbehelpful.TYPICALORDEVELOPMENTAL Provide educaon addressing concern (eg, expectaons for aenon as a funcon of age)Enhanced Surveillance Apparently typical or developmental variation?Yes Evaluationmightrevealthatthechilds/adolescentsinattention,ac-tivitylevel,andimpulsivityarewithinthenormalrangeofdevelopment;mildlyorinconsistentlyelevatedincomparisontopeers;ornotassoci-atedwithanyfunctionalimpairmentinbehavior,academics,socialskills,orotherdomains.Itisimportantforthecliniciantoprobefurthertode-termineiftheparentalconcernsre-gardingthechild/adolescentareat-tributabletootherissuesinthefamily,suchasparentaltensionordrugabuseinanotherfamilymem-ber;whethertheyarecausedbyotherissuesinschool,suchassocialpressuresorbullying;orwhethertheyarewithinthespectrumoftypi-caldevelopment.Parenteducationaboutcontributionstotheircon-cernsandtothespectrumofdevel-opmentalvariationmightbehelpful.Educationabouttherangeoftypicaldevelopmentandstrategiesforim-provingachilds/adolescentsbe-haviorswhentheyareproblematicmightbehelpful.Ascheduleofen-hancedsurveillanceabsolvesthefamilyoftheneedtoreinitiatecon-tactifthesituationdeteriorates.Ifarecommendationforcontinuedrou-tinesystematicsurveillanceismade,thenassurancethatongoingcon-FROMTHEAMERICANACADEMYOFPEDIATRICS cernscanberevisitedinfuturepri-marycarevisitswouldbeimportant.INATTENTION,HYPERACTIVITY,AND/ORIMPULSIVITY(PROBLEMLEVEL):Children/adolescentswhosesymptomsdonotmeetthecriteriafordiagnosisofADHDmightstillencounterdif“cultiesorimpairmentinsomesettings,asde-scribedintheDSM-PCChildandAdoles-centVersion.Professionalconsensusisthatmedica-tionisnotanappropriatetreatmentforchildren/adolescentswithinattention,hyperactivity,and/orimpulsivityprob-lemsthatdonotmeettheDSM-IV-TRcri-teriaforADHD.Children/adolescentswiththeseproblemsandtheirfamiliesmightbene“tfromeducation,includingidentifyingandeliminatingtriggersthatpromptinattention,hyperactivity,orim-pulsivity;behavior-managementoptions,includingabehavior-therapyorparent-ingprogram;strategiesforimprovingschoolperformanceorbehavior;andtherecommendationsprovidedintheinat-tentionandhyperactivity/impulsivityclusterguidanceintheTaskForceonMentalHealthADHDtoolkit.Ifthechild/adolescentisfoundtomeettheDSM-IV-TRcriteriaforADHD,includ-ingcommensuratefunctionaldisabili-ties,suchdiagnosisshouldbemade,andprogressthroughtheprocess-of-careal-gorithmcontinuesasshown.ProvideEducationtotheFamilyandEducationforthefamilyandchild/adolescentaboutADHDisanimpor-tantelementinthecareplanwhenADHDisdiagnosedorinattention,hy-peractivity,and/orimpulsivity(prob-lemlevel)isidenti“ed.Familyeduca-tioncontinuesthroughoutthecourseoftreatment.Itincludesan-ticipatoryguidanceinsuchareasastransitions(eg,fromelementarytomiddleandmiddletohighschoolsandfromhighschooltocollegeoremployment)andworkingwithschoolsanddevelopmentalchal-lengesthatmightbeaffectedbyADHD,includingdriving,gender,andFamilyeducationincludesallmem-bersofthefamily,includingdevelop-mentallyage-appropriateinformationfortheaffectedchild/adolescentandanysiblings.Topicsincludethedisor-der;thesymptoms;theassessmentprocess;commonlycoexistingdisor-ders;treatmentchoice

9 sandtheirap-plication,likelyeffects,ando
sandtheirap-plication,likelyeffects,andoutcomes;long-termimplications;impactonschoolperformance;andsocialAcriticalpieceofthetreatmentplanistoempowerchildren/adolescentstounderstandtheirconditionandthedegreeofimpairmentthatithasontheirdailylife,includingstrate-giesforaddressingsymptomsandimpairments.Ateverystage,thised-ucationmustcontinueinamannerconsistentwiththechilds/adoles-centsownlevelofunderstanding.Inaddition,itishelpfulforachild/ado-lescentwithADHDtoknowthenameofanymedicationthatheorshewillbeusingaswellascommonadverseTheissueofhowthepatientthinksofhimselforherselfisanotherareatoaddress;itshouldbeclari“edthattheconditiondoesnotmeanthathe Inattention and/or hyperactivity/impulsivity problems not rising to DSM-IV DiagnosisProvide educaon of family and child re: concerns (eg, triggers for inaenon or hyperacvity) and behavior management strategies or schoolbased strategies Enhanced Apparently typical or developmental variation? Provide educaon to family and child re: concerns (eg, triggers for inaenon or hyperacvity) and behavior-management strategies or diagnosis of Coexisting conditions?Yes SupplementalAppendixPEDIATRICSVolume,Number, orsheislesssmartthanotherchil-dren/adolescents.Itcanalsobehelpfultoidentifyandsupportareasofstrengthandhelpthechild/ado-lescentwithADHDtolearnhowtoidentifywhenheorsheneedshelpandhowtoprocureit.Educationforparentsshouldincludeproactivestrategiesthatcanhelpmakethehomeenvironmentmorefacilitativefortheirchild/adolescentwithADHD.Forexample,makingad-aptationsandprovidingstructurethatenablesthechild/adolescenttobestusehisorherstrengthsandcompensateforde“citscanbehelp-fultoparents.Suchstrategiesin-cludeprovidinggreaterconsistencyintheparentsbehaviortowardtheirchild/adolescentwithADHD,formingdailyroutinesandschedules,anddisplayinghouserulesinprominentplacesasvisualreminders.Itmayhelpparentstocommunicateabouttheirchilds/adolescentsbehaviorandeachparentsresponseaswellastheparentaldivisionoflabor.Itisalsoimportanttocheckonthepar-entswell-being,becauseparentsofchildren/adolescentswithADHDfre-quentlyareunderstressandmightnottakeintoconsiderationtheirownwell-beingorthatofotherfamilymembers.Theseconcernsarepar-ticularlyrelevantwhenaparentalsohasADHDorassociatedconditions.Parentswilllikelybene“tiftheylearnaboutoptimalwaystopartnerwithschoolssuchthatteacherscanbe-comepartoftheeducationalandinter-ventionteams.Parentswillbene“tfrombeinginformedaboutschoolser-vicesthatareavailabletoaddresstheirchilds/adolescentsneeds,in-cludingtheIndividualsWithDisabili-tiesEducationAct(IDEA)andtheReha-bilitationAct(504)servicesprovidedbytheirstate,andtheeligibilityre-quirementsforthem.Withaparentspermission,thecliniciancanprovidetheschoolwithinformationfromtheevaluationthatwillhelptheschoolde-termineeligibilityforspecialeduca-tionservicesanddevelopappropriateadaptations.AdvocacyandsupportgroupssuchasCHADD(ChildrenandAdultsWithAttention-De“cit/Hyperac-tivityDisorder)canalsoprovideinfor-mationandsupporttofamilies.TheADHDtoolkitprovideslistsofed-ucationalresourcesincludingWeb-basedresources,organizations,andbooksthatmightbeusefultoparentsandstudents.COEXISTINGCONDITIONS:Ifotherdisordersaresuspectedorde-tectedduringthediagnosticevalua-tion,anassessmentoftheurgencyoftheseconditionsandtheirimpactontheADHDtreatmentplanneedstobeUrgentconditions,suchassuicidalthoughtsoractsorotherbehaviorswiththepotentialtoseverelyinjurethechild/adolescentorotherpeo-ple,suchasseveretemperout-burstsorchildabuse,shouldbead-dressedimmediatelywithservicescapableofhandlingcrisisTheevidenceshowsthatcoexistingconditions,suchasoppositionalityandanxiety,mightimprovewithtreatmentofADHD.Forexample,childrenwithADHDandcoexistinganxietydisordersmight“ndthatADHDmedicationsde-creaseanxietysymptomsaswellasADHDbehaviors.Inthecasesofseverelearningdisordersoroppositionalde-“antdisorder,atrialoftreatmentforADHDmightindicatewhethertheap-parentcoexistingconditioncanbemodulatedwithtreatmentoftheADHD.Otherpatientsmightrequireaddi-tionaltherapeutictreatments,suchascognitivebehavioraltherapyoradif-

10 ferentoradditionalmedication,toad-equate
ferentoradditionalmedication,toad-equatelytreattheADHDandcoexistingUntreatedsubstanceusedisorderneedstobeaddressed“rstbeforefullyaddressingthepatientsADHDIftheprimarycareclinicianrequirestheadviceofanothersubspecialist,thentheclinicianshouldconsidercarefullywhentoinitiatetreatmentforADHD.Insomecases,itmightbeadvis-abletodelaythestartofmedicationuntiltheroleofeachmemberofthetreatmentteamisestablished.Forex-ample,withsomecoexistingpsychiat-ricdisorders,suchassevereanxiety,depression,andbipolardisorder,aco-managingdevelopmentalbehavioralpediatricianorpsychiatristmighttake Assess impact on treatment planFurther evaluation/referral as needed Coexisting disorders preclude primary care Follow-up and establish co-management planSee TFOMH AlgorithmsYes Provide educaon to family and child re: concerns (eg, triggers for inaenon or hyperacvity) and behavior-management strategies or Yes diagnosis of ADHD? Coexisting conditions? Yes FROMTHEAMERICANACADEMYOFPEDIATRICS responsibilityfortreatmentofboththeADHDandthecoexistingillness.Atothertimes,suchasinthecaseofachildoradolescentwithcoexistingmilddepressionorobsessive-compulsivedisorder,amentalhealthclinician,developmental-behavioralpediatrician,neurodevelopmentaldis-abilityclinician,orchildneurologistmaytreatthecoexistingconditionwhiletheprimarycareclinicianover-seesthetreatmentforADHD,ortheconsultingphysicianmayadvisetheprimarycarephysicianaboutthetreatmentofthecoexistingconditiontotheextentthattheprimarycarephy-sicianiscomfortabletreatingboththeADHDandcoexistingproblems. ESTABLISH MANAGEMENT TEAM Identify child as CYSHCN Establish team including coordination plan Collaborate with family, school, and child to identify target goals. IDENTIFYASACHILD/YOUTHWITHSPECIALHEALTHCARENEEDS:AnychildwhomeetsthecriteriaforADHDshouldbeconsideredachild/youthwithspecialhealthcareneeds.TheAAPencouragesclinicianstode-velopsystemsthatensurethatthemedicalhomeneedsofallchildren/youthwithchronicillnessesaremet.Theseneeds„andstrategiesformeetingthem„arediscussedinfur-therdetailelsewhereinthisguidelineandinotherAAPresourcessuchasTheBuildingYourMedicalHomeTool-AddressingMentalHealthCon-cernsinPrimaryCare:ACliniciansManagementIssuesQuestionsthatareimportanttocon-siderindevelopingamanagementplanincludethefollowing:Doesthefamilyneedfurtherassis-tanceinunderstandingthecoresymptomsofADHDandtheirchilds/adolescentstargetsymptomsandcoexistingconditions?Doesthefamilyneedsupportinlearninghowtoestablish,measure,andmonitortargetgoals?Havethefamilysgoalsbeenidenti-“edandaddressedinthecareplan?Doesthefamilyhaveanunderstand-ingofeffectivebehavior-managementtechniquesforre-spondingtotantrums,oppositionalbehavior,orpoorcompliancetore-questsandcommands?Ishelpneededfornormalizingpeerandfamilyrelationships?Doesthechild/adolescentneedhelpinacademicareas?Ifso,hasafor-malevaluationbeenperformedandreviewedtodistinguishworkpro-ductionproblemssecondarytoADHDfromcoexistinglearningorlanguagedisabilities?Doesthechild/adolescentneedhelpinachievingindependenceinself-helporschoolworkproduction?Doesthechild/adolescentorfamilyrequirehelpwithoptimizing,orga-nizing,planning,ormanagingschoolwork”ow?Doesthefamilyneedhelpinrecog-nition,understanding,ormanage-mentofcoexistingconditions?Isthereaplaninplacetosystemat-icallyeducatethechild/adolescentaboutADHDanditstreatmentaswellasthechilds/adolescentsownstrengthsandweaknesses?Isthereaplaninplacetoempowerthechild/adolescentwiththeknowl-edgeandunderstandingthatwillin-creasehisorheradherencetotreatments,andhasthatbegunasearlyaspossibleandbeenad-dressedatthechilds/adolescentsdevelopmentallevel?Doesthefamilyhaveacopyofacareplanthatsummarizes“ndingsandtreatmentrecommendationsthatcanbeupdatedandusedinschoolsettingsandotherprofessionalset-tingssothatthehistoryandtreat-mentplandoesnotneedtobecon-stantlyreinvented?Isthefollow-upplansuf“cienttoprovidecomprehensive,coordi-nated,family-centered,culturallycompetent,ongoingcare?COLLABORATEWITHTHEFAMILY,SCHOOL,ANDCHILD/ADOLESCENTTOIDENTIFYTARGETGOALS:Whereasaninitialstimulantmedica-tiontrialmightf

11 ocusonnormalizingcoresymptomsofADHD,alon
ocusonnormalizingcoresymptomsofADHD,alonger-termcomprehensiveplanshouldfocusonidentifyingandaddressingindividual-izedandspeci“cbehavioral,academic,andsocialtargetgoalsandtreat-ments.Theclinicianshouldassistpar-ents,teachers,otherinformants,andthechild/adolescentindevelopingtar-getgoalsintheareasoffunctionmostcommonlyaffectedbyADHD:academ-ics;peer,parent,orsiblingrelation-ships;andsafetyinthecommunity.Othergoalsmightbeidenti“edbyus-ingtheInternationalClassi“cationofFunction(ICF)analysisconductedinthediagnosticphaseoftheclinicalItisnotnecessarytodevelopgoalsineveryareaallatonce.Familiesmightbeencouragedtoidentifyupto3ofthemostimpairingareasonwhichtheywillinitiallywork;parentsandthechild/adolescentcanthenaddothertargetsasindicatedbytheirrelativeimportance.Suchanexercisewillfacil-itategreaterunderstandingoftheef-fectsofthedisorderoneachmemberofthefamilyandmightleadtoanim-provedcollaborationinthedevelop-mentofafewspeci“candmeasurableoutcomes.Itishelpfultoincorporatethechilds/adolescentsstrengthsandresilientfactorsinconsideringtargetgoalsandingeneratingatreatmentplan.Goalsfortheschoolrequireinputfromtheteachersintermsofbothidenti“cationandmeasurement.SupplementalAppendixPEDIATRICSVolume,Number, Establishingmeasurablegoalsinin-terpersonaldomainsandbehaviorinunstructuredsettingsmightbepartic-ularlyimportant.Wheneverpossible,itisimportanttomakeprogresscount-able.ŽForbehaviorssuchasfre-quencyofyellingŽorfrequencyofmissingassignments,chartsmaybesuggestedasstrategiesforrecordingtheeventsothatparents,teachers,thechild/adolescent,andclinicianscanallagreeonhowmuchprogresshasbeenmade.Inthisway,successescanbebuiltoninasystematicway.Suchstrategiescanhelpafamilyaccuratelyassessandseeprogressofbehaviorchanges.Adailysingle-pagereportcardcanbeusedtoidentifyandmoni-tor4or5behaviorsthataffectfunctionatschool,andthesereportscanbesharedwiththeparents.Otherstrate-giesandtoolsareavailabletoclini-ciansintheAAPADHDtoolkitandtoparentsinthebookADHD:WhatEveryParentNeedstoKnowAstreatmentproceeds,inadditiontousingaDSM-IV-TR…basedADHDratingscaletomonitorcoresymptomchanges,formalandinformalqueriescanbemadeintheareasoffunctionmostcommonlyaffectedbyADHD(eg,academicachievement;peer,parent,orsiblingrelationships;andsafetyinthecommunity).Progresscanalsobemonitoredbydeterminingprogressonthetargetgoals.Ateveryvisit,itishelpfultograduallyempowerchil-dren/adolescentstobecomefullpart-nersintheirtreatmentplanbyadoles-cence.Informationfromtheschool,includingADHDsymptoms(ratingscalecompletedbytheteacher),grades,andanyotherformaltestingresults,arealsohelpfulatthesevisits.ESTABLISHTEAMANDCOORDINATIONPLAN:Itisbestforthetreatmentteamtoin-cludeeveryoneinvolvedinthecareofthechild/adolescent:thechild/adoles-cent,parents,teachers,theprimarycareclinician,therapists,subspecial-ists,andotheradults(suchascoachesorreligiousleaders)whowillbeac-tivelyengagedinsupportingandmon-itoringthetreatmentofADHD.ItishelpfulfortheprimarycareclinicianoranassignedcarecoordinatorŽtoensurethateachteammemberisawareofhisorherroleandthatbothroutineandas-neededcommunicationstrategiesandexpectationsforre-ports(frequency,scope)areclear.Col-laborationwiththeschoolgoesbe-yondtheinitialreportofdiagnosisandisbestfacilitatedbyagreementonastandardized,reliablesystemforex-changingcommunications.Thistreatmentoptionisrestrictedtochildren/adolescentswhomeetthedi-agnosticcriteriaforADHD.Althoughitisarareoccurrenceandmoreevidenceisrequiredtoidentifywhetheritisanincreasedrisk,itisimportanttoobtainacarefulhistoryofcardiacsymp-toms;acardiacfamilyhistory,par-ticularlyofarrhythmias,suddendeath,anddeathatayoungagefromcardiacconditions;andvitalsigns,cardiacphysicalexamina-tion,andfurtherevaluationonthebasisofclinicaljudgment.Stimulantmedicationsandseveralnonstimulantmedicationsarenowavailable,asoutlinedinTable3.ThepresenceofaticdisordermightaffectthedecisionaboutwhichmedicationtoinitiateforADHDther-apy.WiththegreateravailabilityofmedicationsapprovedbytheFDAforchildren/adolescentswithADHD,ithasbecomeincreasinglyunlikelythatclini-ciansneedtoconsidertheoff-labeluseof

12 othermedications.Thechoiceoffor-mulation
othermedications.Thechoiceoffor-mulationdependsonfactorssuchastheef“cacyofeachagentforagivenchild/adolescent,thepreferredlengthofcoveragetime,whetherachildcanswallowpillsorcapsules,andex-pense.Theextended-releaseformula-tionsaregenerallymoreexpensivethantheimmediate-releaseformula-tionsbutmightbepreferredbymanyfamiliesandchildren/adolescents,be-causetheyprovidethebene“tsofcon-sistentandsustainedcoveragewithfeweradministrationsperday.Long-actingformulationsusuallyprecludetheneedforschool-basedadministra-tionofADHDmedication.Bettercover-agewithfeweradministrationsleadstogreaterconvenienceforthefamilyand,therefore,mightalsoleadtobet-teradherencetothemedicationman-agementplan.Somepatients,particu-larlysomeadolescents,mightrequiremorethan12hoursofcoveragetoen-sureadequatefocusandconcentra-tionduringeveningstudytimeanddriving;inthesecases,ashort-actingpreparationmightbeusedinadditiontoalong-actingpreparation.Theeasewithwhichpreparationscanbeadministeredandtheminimizationofadverseeffectsareimportantforthequality-of-lifeconcernsthatchil-dren,youth,andparentsexpressaroundthedecisiontousemedication. Opon: Medicaon(ADHD only and past medical or family history of cardiovascular disease considered) Iniate treatment Titrate to maximum bene“t, minimum adverse eects Monitor target outcomes Opon: Behavior management (developmental variaon, problem or ADHD) Idenfy service or approach Monitor target outcomes Opon: Collaborate with school to enhance supports and services (developmental variaon, problem, or ADHD) Idenfy changes Monitor target outcomesSee action statement 5See action statement 6BEGIN TREATMENT FROMTHEAMERICANACADEMYOFPEDIATRICS Othercontextissuesthatshouldalsobeconsideredindecidingwhichmed-icationtorecommendincludethetimeofdaywhenthetargetedsymptomsoccur,whenhomeworkisusuallydone,whethermedicationremainsac-tivewhenteenagersaredriving,whethermedicationalterssleepinitia-tion,andriskstatusfordruguse.Allapprovedstimulantmedicationsaremethylphenidateoramphetaminecompounds,whichhavesimilareffectsandadverseeffects.Giventheexten-siveevidenceofef“cacyandsafety,theyremainthe“rstchoiceofmedica-tiontreatment.Thus,thedecisionre-gardingwhichcompoundaclinician“rstprescribesshouldbemadeonthebasisofindividualpreferencesoftheclinicianandfamily.Somechildren/ad-olescentswillrespondbettertoordis-playmoreadverseeffectswith1com-poundgrouportheother.Becausetheseeffectscannotbedeterminedinadvance,ifatrialwith1groupisun-successful(pooref“cacyoradverseeffects),atrialonamedicationfromtheothergroupshouldbeundertaken.Forcasesinwhichthereisconcernaboutpossibleabuseordiversionofthemedicationorthereisastrongfamilypreferenceagainststimulantmedication,anFDA-approvednon-stimulantmedicationmaybeconsid-eredasthe“rstchoiceofmedication.Themedicationsthatuseamicrobeadtechnologycanbeopenedandsprin-kledonfoodforpatientswhohavedif-“cultyswallowingtabletsorcapsules.Immediate-releasemethylphenidate,whichcomesinliquidandchewableforms,andamethylphenidatetrans-dermalpatcharealsoavailableasal-ternativestotabletsorcapsules.Itishelpfultopreparefamiliesfortheinitialmedication(titration)process,includingwhatitwillentailandhowlongitmighttake.Theusualprocedureistobeginwithalowdoseofmedica-tionandtothedosethatpro-videsmaximumbene“tandminimaladverseeffects.Initially,coresymp-tomreductionismorelikelytoindicatemedicationeffects;theeffectsofim-SUPPLEMENTALTABLE3FDA-ApprovedMedications:DosingandPharmacokinetics MedicationBrandInitialTitrationDoseFrequencyTimetoInitialEffectDuration,hMaximumDoseAvailableDosesMixedamphetamine2.5…5.0mgQD…BID20…60min640mg5.0-,7.5-,10.0-,12.5-,15.0-,20.0-,and30.0-mgtabletsAdderallXR5mgQD20…60min1040mg5-,10-,15-,20-,25-,and30-mgDextroamphetamineDexedrine2.5mgBID…TID20…60min4…640mg5-and10-mg(Dextrostatonly)5mgQD…BID60min640mg5-,10-,and15-mgcapsulesLisdexamfetamineVyvanse20mgQD60min10…1270mg20-,30-,40-,50-,60-,and70-mgcapsulesMethylphenidateConcerta18mgQD20…60min1254mg(13y);72mg(13y)18-,27-,36-,and54-mgMethylER10mgQD20…60min860mg10-and20-mgtabletsMethylin5mgBID…TID20…60min3…560mg5-,10-,and20-m

13 gtabletsandliquidandchewableformsDaytran
gtabletsandliquidandchewableformsDaytrana10mgApplyfor9h60min11…1230mg10-,15-,20-,and30-mg5mgBID…TID20…60min3…560mg5-,10-,and20-mgtabletsRitalinLA20mgQD20…60min6…860mg20-,30-,and40-mgcapsulesRitalinSR20mgQD…BID1…3h2…660mg20-mgcapsulesMetadateCD20mgQD20…60min6…860mg10-,20-,30-,40-,50-,and60-mgcapsulesDexmethylphenidateFocalin2.5mgBID20…60min3…520mg2.5-,5.0-,and10.0-mgtabletsFocalinXR5mgQD20…60min8…1230mg5-,10-,15-,and20-mgAtomoxetineStrattera0.5mg/kgperd,thenincreaseto1.2mg/kgperd;40mg/dforadultsandchildrenat154lb,upto100mg/dQD…BID1…2wkAtleast10…12h1.4mg/kg10-,18-,25-,40-,60-,80-,and100-mgcapsulesIntuniv1mg/dQD1…2wkAtleast10…12h4mg/d1-,2-,3-,and4-mgtabletsKapvay0.1mg/dQD…BID1…2wkAtleast10…12h0.4mg/d0.1-and0.2-mgtabletsQDindicatesdaily;BID,twicedaily;TID,threetimesdaily.Availableinagenericform.Dosagesforthedermalpatcharenotequivalenttothoseoftheoralpreparations.SupplementalAppendixPEDIATRICSVolume,Number, provementinfunctionrequireamoreextendedtimeperiod.Stimulantmedi-cationscanbeeffectivelytitratedona3-to7-daybasis.Duringthe“rstmonthoftreatment,medicationdosemaybetitratedwithaweeklyorbiweeklytele-phonecalltothefamily.Theincreasingdosescanbeprovidedeitherbypre-scriptionsthatallowdoseadjust-mentsupwardor,forsomeofthemed-ications,by1prescriptionoftablets/capsulesofthesamestrengthwithinstructionstoadministerprogres-sivelyhigheramountsbydoublingortriplingtheinitialdose.Anotherap-proachsimilartothatusedintheMTAisforparentstobedirectedtoadministerdifferentdosesofthesamepreparation,eachfor1weekatatime(eg,SaturdaythroughFriday).Attheendofeachweek,teacherandparentfeedbackand/orDSM-IV-TR…basedADHDratingscalescanbecompletedthroughatelephoneinterview,fax,orsecureelectronicsystem.InadditiontotheADHDratingscale,parentsandteachersshouldbeaskedtoreviewad-verseeffectsandtargetgoals.Aface-tofacefollow-upvisitisrecom-mendedbythefourthweekofmedica-tion,duringwhichcliniciansreviewtheresponsestothevaryingdosesandmonitoradverseeffects,pulse,bloodpressure,andweight.Toensurethatprogressinsymptomcontrolisbeingmaintained,cliniciansshouldcontinuetomonitorlevelsofcoresymptomsandimprovementinspeci“edtargetgoals.Ageneralguideforvisitstotheprimarycareclinicianisforthefacetofacevisitstooccurinitiallyonamonthlybasis,untilthereisaconsis-tentoptimalresponse,andthenevery3monthsinthe“rstyearoftreatment.Subsequentvisitswilldependontheresponsebutshouldoccuratleast2timesperyear,untilitisclearthattar-getgoalsareprogressingandstable,andthenperiodicallyasdeterminedbythefamilyandtheclinician.Recentre-sultsfromtheMTAstudyindicatethatthereareanumberofchildren/adoles-centswho,by3yearsafterstartingmedication,continuetoimproveevenifthemedicationhasbeendiscontin-The“ndingssuggestthatchil-dren/adolescentswhoarestableintheirimprovementofADHDsymptomsmaybegivenatrialoffmedicationaf-terseveralyearstodetermineifmed-icationisstillneeded.Thisprocessisbestundertakenwithclosemonitoringofthechilds/adolescentscoresymp-tomsandfunctionathome,inschool,andinthecommunity.Wheneverpossible,improvementsincoresymptomsandtargetgoalsshouldbemonitoredinanobjectiveway(eg,goingfrom60%to20%miss-ingassignmentsperweek[seetheADHDtoolkit]),andthecoresymp-tomscanbemonitoredbyuseofoneoftheDSM-IV-TR…basedADHDratingscalessuchastheVanderbiltADHDfollow-upscales.Cliniciansareen-couragedtoeducateparentsthatal-thoughmedicationcanbeeffectiveinfacilitatingschoolworkproduc-tion,ithasnotbeenshowntobeef-fectiveinaddressinglearningdis-abilities.Achild/adolescentwhocontinuestoexperienceacademicunderachievementafterattainingsomecontrolofADHDbehavioralsymptomsshouldbeassessedforacoexistingcondition,includinglearn-ingandlanguagedisabilities,othermentalhealthdisorders,orotherpsychosocialstressors.Noncompli-ancewiththetreatmentplanshouldalsobeassessed.Ifthemaximumdoseofastimulantpreparationisreachedandless-than-satisfactoryresultshavebeenachievedorintolerableadverseef-fectsoccurbeforeadequateef“cacywithamedicationfromoneofthestimulantgroups(methylphenidateoramphetamine),amedicationfromtheotherstimulantgroupshouldberecommendedwithasimilartitra-tionplan.Atleasthalfofth

14 echil-dren/adolescentswhosesymptomsfailt
echil-dren/adolescentswhosesymptomsfailtorespondto1stimulantmedi-cationmayhaveapositiveresponsetothealternativemedication.Familiesconcernedabouttheuseofstimulantsorwithconcernsaboutabuseordiversionmaychoosetostartwithatomoxetineorextended-releaseguanfacineorextended-releaseclonidine.Inaddition,thosewhosesymptomsdonotrespondtoeitherstimulantgroupmightstillre-spondtoatomoxetineorextended-releaseguanfacineorextended-releaseclonidine.Extendedreleaseguanfacineorextendedreleaseclo-nidinealsomaybeaddedasanad-junctivetherapyinchildrenwhopar-tiallyrespondtostimulantThereisablock-boxwarningonatomoxetineofthepossibilityofsuicidalideationwheninitiatingmedicationmanagement.Earlysymptomsofsuicidalideationmightincludethinkingaboutself-harmandincreasingagitation.Ifthereareanyconcernsaboutsui-cidalideationinchildrenpre-scribedatomoxetine,furtherevalu-ation,reconsiderationabouttheuseofatomoxetine,andmorefre-quentmonitoringshouldbeconsid-ered,andifnecessary,referraltoamentalhealthclinicianshouldbeAtomoxetineisaselectivenorepinephrine-reuptakeinhibitorandmightresultinmaximumre-sponseonlyafterapproximately4to6weeks.Extended-releaseguanfacineandextended-releaseclonidineareA-adrenergicagonistsandmightresultinmaximumresponseinapproxi-mately2to4weeks.Parentsmaybeencouragedtocompleteweeklysymp-tomandadverse-effectmonitoring,asFROMTHEAMERICANACADEMYOFPEDIATRICS describedpreviously,asanobjectivemeasuretomonitoref“cacy.BecausesymptomchangeismoregradualwithatomoxetineandA-adrenergicagoniststhanwithstimulantmedications,familieswhohavehadpreviousexpe-riencewithstimulantsshouldbemadeawareofthisfact.Insomepatients,amodesteffectofatomoxetinemightbeseenin1week.Atomoxetinemightcausegastrointestinaltractsymptomsandsedationearlyintreatment,soitisrecommendedtoprescribehalfthetreatmentdose(0.5mg/kg)forthe“rstweek.Appetitesuppressioncanalsooccur.BothAagonistscancausetheadverseeffectofsomno-lence.Inaddition,itisrecommendedthatthemedicationsbetaperedwhendiscontinuedtopreventapossiblere-boundinbloodpressure.SpecialCircumstances:Preschool-AgedChildrenCliniciansshouldinitiateADHDtreat-mentofpreschool-agedchildren(4…5yearsofage)withbehaviortherapyandshouldalsoassessforotherdevelopmentalproblems,es-peciallywithlanguage.Ifchildrendonotexperienceadequatesymptomandfunctionalimprovementwithbe-haviortherapy(mostprogramsare10…14weekslong,buttheclinicianshouldcheckwiththetherapistsabouttheirusuallengthofinterven-tion),theclinicianshould“rstevalu-atetheadequacyandparentalac-ceptanceofthetherapy.Ifthesymptomsand/orfunctioninghavenotimprovedandthechildisatsig-ni“cantbehavioralordevelopmentalriskbecauseofADHD,medicationcanbeprescribed,asdescribedpre-viously.Itmustbenotedthat,cur-rently,theFDAhasonlyapproveddextroamphetamineforADHDinchil-dreninthisagegroup,althoughthereislittleevidencetosupportitssafetyandef“cacy.Thereis,how-ever,evidencethatmethylphenidateissafeandef“caciousforchildreninthisagegroup.thattherateofmetabolizingmethyl-phenidateisslowerinchildren4and5yearsofage,sotheyshouldbestartedatalowerdosethatisin-creasedinsmallerincrements.Inad-dition,thepreschool-agedchildrenstudiedinthemultisitestudymoreseveredysfunction,whichshouldbeconsideredinthedecisiontotrytreatmentwithmethylpheni-date.Theadditionalcriteriaforde-“ningmoderate-to-severeimpair-mentincludesymptomspresentforatleast9monthsandclearimpair-mentinboththehomeanddaycare/preschoolsettingsthathasnotre-spondedtoanappropriatebehavioralintervention.Limitedevi-andnoFDAapprovalforchil-dreninthisagegroupareavailableforatomoxetine,andnoevidenceorapprovalforextended-releaseguan-facineorextended-releaseclonidineareavailable.SpecialCircumstances:AdolescentsCliniciansshouldassessadolescentpatientswithADHDforsymptomsofsubstanceuseorabusebeforebegin-ningmedicationtreatment.Ifsub-stanceabuseisrevealed,theyshouldhavethepatientstoptheuse,andtheyshouldprovidetreatmentorreferfortreatmentforsubstanceabusebeforebeginningtreatmentforADHD.Clini-ciansarealsoencouragedtomonitorsymptomsandprescriptionre“llsforsignsofmisuseordiversionofADHDSpecialconcernshouldbetakentoprovidemedicationco

15 verageforADHDsymptomcontrolwhiledriving.
verageforADHDsymptomcontrolwhiledriving.Longer-actingorlate-afternoon/short-actingmedicationsmightbehelpfulinthisregard.Counselingforadolescentsaroundmedicationis-suesshouldincludedealingwithre-sistancetotreatmentandempower-ingchildren/adolescentstotakechargeofandowntheirmedicationmanagementasmuchaspossible.Techniquesofmotivationalinter-viewingmightbeusefulinimprovingSpecialCircumstances:FamiliesandChildren/AdolescentsWhoDeclineThedecisionaboutwhatisthemostacceptabletreatmentfortheirchild/adolescentrestswiththefamily,andtheclinicianmustrespectthatdeci-sion.Theclinicianshould,however,ad-dressanymisinformationorconcernsaboutmedicationsharedbythefamily,encourageallotherdimensionsoftreatment,andprovideappropriateSpecialCircumstances:InattentionorHyperactivity/Impulsivity(ProblemMedicationisappropriateforchil-dren/adolescentswhosesymptomsdonotmeetDSM-IV-TRcriteriafordiagno-sisofADHD.BehaviorManagementEvidence-basedparenttrainingtypi-callybeginswith7to12weeklygroupsessionswithatrainedtherapistorcerti“edinstructor.ThefocusisonparenteducationaboutADHD,thechilds/adolescentsbehaviorprob-lems,anddif“cultiesinfamilyrelation-ships.Atypicalprogramaimstoim-provetheparents/caregiversunderstandingofthechilds/adoles-centsbehaviorandtoteachthemskillstohelpthechild/adolescenttoreducethebehavioraldif“cultiesposedbyADHD.Programsofferspeci“ctechniquesforreinforcingadaptiveandpositivebe-haviorsanddecreasingoreliminatinginappropriatebehaviors,bothofwhichalterthemotivationofthechild/adolescenttocontrolattention,activ-ity,andimpulsivity.TheseprogramsSupplementalAppendixPEDIATRICSVolume,Number, emphasizeestablishingpositiveinter-actionsbetweenparentsandchildren;learninghowtoshapechildrensbe-haviorsthroughcombinationsofpraisingandignoring;howtogivesuc-cessfulcommands;howtoreinforcepositivebehaviors;howtoextinguishinappropriatebehaviorsthroughig-noring;howtoidentifywhichbehav-iorsarehandledmostappropriatelythroughpunishment;anddetermininghowtocarrypunishmentsoutinare-sponsibleway.Theseprogramsallem-phasizeteachingself-controlandbuildingpositivefamilyrelationships.Ifparentsstronglydisagreeaboutbe-haviormanagementorhaveconten-tiousrelationships,parentingpro-gramswilllikelybeunsuccessful.Otherstrategies,suchaschangingthephysicalenvironmenttoreducestim-ulitooveractivity,arealsoeffectivebychangingthestimulithattriggerprob-lembehaviors.Dependingonthese-verityofthechilds/adolescentsbe-haviorsandthecapabilitiesoftheparents,grouporindividualtrainingprogramswillberequired.Programstypicallyincludesupportformainte-nanceandrelapseprevention.Behaviortherapyshouldbedifferenti-atedfrompsychologicalinterventionsdirectedtothechild/adolescentanddesignedtochangethechilds/adoles-centsemotionalstatus(eg,playther-apy)orthoughtpatterns(eg,interper-sonaltalktherapy).Thesepsychologicalinterventionsdonothaveademonstratedef“cacyfortheADHDcoresymptoms,andgainsachievedinthetreatmentsettingusu-allydonottransferintotheclassroomorhome.Bycontrast,parenttraininginbehaviortherapyandclassroombe-haviorinterventionshavesuccessfullychangedthebehaviorofchildren/ado-lescentswithADHD.Behaviortherapyisalsoapplicableforchildren/adoles-centswhohaveproblemsinthedo-mainsofinattentionorhypersensitivi-ty/impulsivitybutdonotmeettheDSM-IV-TRcriteriaandforthosechildren/adolescentswithadevelopmentalUnlessprimarycarecliniciansarespeci“callytrained,havetrainedstafforacolocatedtherapist,ordedicatemanyvisitstoprovidingtheongoingtreatment,theymightnotbeeffectiveinprovidingbehaviortherapy.ciansmightalsohavedif“cultiesde-terminingtheskillsofbehaviorthera-pistslistedinthebehavioralhealthinsuranceplan.Thisdeterminationisimportant,becausemanytherapistsfocusonaplayorinterpersonal-talktherapythathasnotbeenshowntobeeffectiveintreatingthecoresymp-tomsofADHD.Telephoneinquiriesoftherapists,agencies,andmentalhealthcliniciansregardingtheirap-proachtobehaviortherapymightal-lowclinicianstodeveloparesourcelistforparents.Cliniciansmightalsorequestreferencesfromotherpar-entsofchildren/adolescentswithADHD,professionalorganizations(eg,AssociationforBehaviorandC

16 ognitiveTherapies),andADHDadvo-cacyorgan
ognitiveTherapies),andADHDadvo-cacyorganizations(eg,CHADD).Par-entswhohavereadauthoritativelywrittenbooksaboutbehaviorthera-py/behaviorparenttrainingmightbeinabetterpositiontoknowwhattheyarelookingforinatherapistandaskthesalientquestionswhenseekingappropriatetherapists.Someoftheseresourcesareavail-ableintheADHDtoolkitandtheADHD:WhatEveryParentNeedstoKnowClassroombehaviormanagementalsofocusesonshapingthechilds/adoles-centsbehaviorsandmaybeinte-gratedintoclassroomroutinesforallstudentsortargetedforaselectedchild/adolescentintheclassroom.Classroommanagementoftenbeginswithincreasingthestructureofactivi-ties.Tokeneconomyreferstousingpointsortokensthataregivenforpos-itivebehaviors,andresponsecostre-ferstopointsortokenssubtractedforinappropriatebehaviors.Thetokensorpointscanthenbecashedinafterade“nedperiodforrewardsorprivi-leges.Systematicrewards(eg,useofatokeneconomy)areincludedtoin-creaseappropriatebehaviorandelim-inateinappropriatebehavior.Aperi-odic(oftendaily)behaviorreportcardcanrecordthechilds/adolescentsprogressorperformancewithregardtogoalsandcommunicatethechilds/adolescentsprogresstotheparents,whothenprovidereinforcersorcon-sequencesbasedonthatdaysperfor-mance.Suchprogramsarealsousefulforthepurposeofmonitoringmedica-tioneffects.COLLABORATEWITHTHESCHOOLTOENHANCESUPPORTSANDSERVICESManyteachersandschoolshaveeffec-tivestrategiesforsupportingandservingchildren/adolescentswithADHD.Schoolscanimplementbehavior-managementprogramsthatdirectlytargetADHDsymptomsaswellasinterventionstoenhanceacademicandsocialfunctioning.Schoolsmayalsousestrategies(eg,dailybehaviorreportcards)toenhancecommunica-tionwithfamilies.Allschoolsshouldhavespecialists(eg,schoolpsycholo-gists,counselors,specialeducators)whoobservethechild/adolescent,identifytriggersandreinforcers,andsupportteachersinchangingthecir-cumstancesoftheclassroomandmakingaccommodationstoaddressADHDsymptoms,suchaswritten-outputbypassstrategies,untimedtesting,testinginlessdistractingenvi-ronments,preferentialseating,androutinereminders.Cliniciansshouldbeawareoftheeligi-bilitycriteriaforthe504RehabilitationActandtheIndividualsWithDisabilitiesEducationActsupportsintheirstateFROMTHEAMERICANACADEMYOFPEDIATRICS andlocalschooldistrict(s)shouldunderstandtheprocessforre-ferralaswellastheindividualswithwhomthephysicianorparentshouldmakecontact.Thisinformationcanbeprovidedtoparentstosupporttheireffortstorequestclassroomadapta-tionsfortheirchild/adolescentwithADHD,includingtheuseofempiricallysupportedacademicinterventionstoaddressachievementdif“cultiesasso-ciatedwithADHDsymptoms. symptoms improve? Inprovidingamedicalhome,primarycarecliniciansshouldregularlymoni-aspectsofADHDtreatment,tosystematicreassessmentofsymptomsandfunctionregularreassessmentofassurancethatthefamilyis“edwiththecaretheyarereceiv-ingfromothercliniciansandthera-pists,ifapplicable;provisionofanticipatoryguid-,furtherandfamilyeducation,andtransi-tionplanningasneededandassurancethatcarecoordinationisoccurringandmeetingtheneedsofthechild/adolescentandfamily;con“rmationoftoanyprescribedmedicationregimen,withadjustmentsmadeasneeded;heartrate,bloodpressure,height,andweightmonitoring;andcontinuingtoformatherapeuticre-lationshipwiththechild/adolescentandempowerfamiliesandchil-dren/adolescentstobestrong,in-formedadvocates.Sometreatmentmonitoringcanoccurduringgeneralhealthcarevisitsiftheclinicianinquiresaboutprogressto-wardtargetgoals,adherencetomedi-cationandbehaviortherapy,con-cerns,orchanges.Monitoringofchildren/adolescentswithinattentionorhyperactivity/im-pulsivityproblemscanhelptoensureprompttreatment,shouldtheirsymp-tomsworsentotheextentthatadiag-nosisofADHDiswarranted. Reevaluate to confirm diagnosis and/or provide education to improve adherence.Reconsider treatment plan including changing of the medication or dose, adding a medication approved for adjuvant therapy, and/or changing behavioral therapy. ADHDtreatmentfailuremightbeasignofincorrectorincompletediagnosis.Cliniciansareadvisedtorepeatthefulldiagnosticevaluationandpayin-creasedattentiontothepossibilityofcoexis

17 tingconditionsthatmimicorareassociatedwi
tingconditionsthatmimicorareassociatedwithADHD,suchassleepdisorders,Aspergersyndrome,orepilepsy(eg,absenceepilepsyorpartialseizures).Acoexistinglearningdisordermightalsocauseanapparenttreatmentfailure.Inthecaseofachild/adolescentpreviouslydiagnosedwithproblem-levelinattentionorhy-peractivity,repeatingthediagnosticevaluationmightresultinadiagnosisofADHD,whichwouldallowforin-creasedschoolsupportsandtheinclu-sionofmedicationinthetreatmentTreatmentfailurecouldalsosignalpooradherencetothetreatmentplan.Increasedmonitoringandeducation,especiallybyincludingthepatientearlyinhisorhertreatment,mightin-creasetreatmentadherence.Itishelp-fultotrytoidentifytheissuesthatre-strictadherence. Yes chronic care management at least 2x/year for ADHD issues Intheearlystagesoftreatment,afterasuccessfultitrationperiod,thefre-quencyoffollow-upvisitswilldependonadherence,coexistingconditions,andpersistenceofsymptoms.Asnotedpreviously,ageneralguideforvisitstotheprimarycareclinicianisforthesevisitstooccurinitiallyonamonthlybasis,thenevery3monthsinthe“rstyearoftreatment.Morefre-quentvisitsmightbenecessaryifco-morbidconditionsarepresent.Visitsshouldthenbeheldatleasttwiceeachyearwithadditionaltelephonemoni-toringatthetimeofmedication-re“llrequests.Ongoingcommunicationwiththeschoolregardingmedicationandservicesisalsoneeded.Itshouldbenotedthatatthispoint,thereislittleevidencetoestablishtheoptimal,yetpractical,follow-upregi-men.Itislikelythattheregimenwillneedtobetailoredtotheindividualchild/adolescentandfamilyneedsonthebasisofclinicaljudgment.PREPARINGTHEPRACTICESpeci“cof“cepracticeproceduresthatfacilitatetheoptimalandef“cientdiagnosisandtreatmentprocessarecriticalforsuccessfulmanagementofchildren/adolescentswithADHD.MoredetailcanalsobefoundinthereportoftheAAPTaskForceonMentalHealth.Theof“ceprocesscaninclude:developingapacketofADHDques-tionnairesandratingscalesforpar-entsandteacherstocompletebe-foreascheduledvisit;allottingadequatetimeforADHD-relatedvisits;determiningappropriatebilling,documentation,andmonitoringofinsurancepaymentstoensurethattheyadequatelycovertheservicesimplementingmethodstotrackandSupplementalAppendixPEDIATRICSVolume,Number, follow-uppatients(refertomedicalhomeproceduresformoredetail);askingquestionsduringallclinicalencountersandplacingbrochuresandpostersintheof“cetoalertpar-entsandchildren/adolescentsthatbehaviorandschoolproblemsandADHDareappropriateissuestodis-cusswiththeclinician;developinganof“cesystemformonitoringandtitratingmedication(afollow-upsystemshouldincludethecliniciansassessmentoffamilyorganization,telephoneaccess,andparent-teachercommunicationef-fectiveness);andcollaboratingwithschoolsandotherinvolvedcommunityprovidersandresourcesthatcanenhancetheprocessforADHDdiagnosisandmanagement,whichcanbeachievedonacase-by-casebasisthroughcoordinationofthediagno-sisandtreatmentplanamongschoolstaff,theclinician,parents,andotherinvolvedprofessionals(notethatthisless-systematicap-proachcarriessigni“cantchal-lenges,includingensuringconsis-tentcareforallchildren/adolescentswithADHD).Acommunity-levelsystemthatre”ectsconsensusamongdistrictschoolstaffandlocalprimarycarecliniciansforkeyelementsofdiagnosis,interven-tions,andongoingcommunicationcanhelptoensureconsistent,well-coordinated,andcost-effectivecare.Acommunity-basedsystemwithschoolsrelievestheindividualprimarycareclinicianfromnegotiatingwitheachschoolaboutcareandcommunicationregardingeachpatient.Of“cesthathaveincorporatedmedicalhomeprin-ciplesareidealforestablishingthiskindofcommunity-levelsystem.Thekeyelementsforacommunity-basedcollaborativesystemincludeconsen-suson:aclearandorganizedprocessbywhichanevaluationcanbeinitiatedwhenconcernsareidenti“edbyei-therparentsorschoolpersonnel;apacketofinformationcompletedbyparentsandateacherabouteachchild/adolescentreferredtotheprimarycareclinician;acontactpersonatthepracticetoreceiveinformationfromparentsandteachersatthetimeofevalua-tionandduringfollow-up;anassessmentprocesstoinvesti-gatecoexistingconditions;adirectoryofevidence-basedinter-ventionsavailableintheanongoingprocessforfollow-u

18 pvisits,telephonecalls,teacherre-ports,a
pvisits,telephonecalls,teacherre-ports,andmedicationre“lls;availabilityofformsforcollectingandexchanginginformation;andaplanforkeepingschoolstaffandprimarycarecliniciansup-to-dateontheprocess.Theclinicianmightfacechallengestodevelopingsuchacollaborativepro-cess.Asexamples,theprimarycareprovidermightbecaringforchildren/adolescentsfrommorethan1schoolsystem;aschoolsystemmightbequitelargeandnoteasilyaccessed;schoolsmighthavelimitedstaffandresourcestocompleteassessments;oritmightbedif“cultforthephysicianandteacherorotherschoolpersonneltocommunicatebytelephonebecausetheirschedulesdiffer.Therearework-ablestrategiesforaddressingeachofthesechallenges.Inthecaseofmultipleorlargeschoolsystemsinacommunity,theprimarycareclinicianmightwanttobeginwith1schoolpsychologistorprincipal,orseveralpracticescaninitiatecontactcollectivelywithacommunityschoolsystem.Agreementamongtheclini-ciansonthecomponentsofagoodevaluationprocessfacilitatescooper-ationandcommunicationwiththeschooltowardcommongoals.Forex-ample,agreementonthebehaviorrat-ingscalesusedcanfacilitatecomple-tionbyschoolpersonnel.Standardcommunicationformsthatmonitorprogressandspeci“cinterventionscanbefaxedbetweentheschoolandthepediatricof“cetoshareCollaborativesystemsalsoextendtootherproviderswhomaycomanagecarewiththeprimarycareclinician.Providersmayincludeamentalhealthprofessionalwhoseesthechild/ado-lescentforpsychosocialinterventionsoraspecialistwhoaddressesdif“cultcases,suchasadevelopmental-behavioralpediatrician,childpsychia-trist,childneurologist,neurodevelop-mentaldisabilityphysician,orpsychologist.Agreed-onprocessesforroutinecommunicationcanalsobeusedintheserelationships.TheAAPTaskForceonMentalHealthprovidesafulldiscussionofcollaborativerela-tionshipswithmentalhealthprofes-sionals,includingcolocationandinte-gratedmodels,initsChapterActionandPedialinkModule.Itisimportanttonotethatgoodcarefrequentlyrequiresactivitiesthatcur-rentlyarenotreimbursed.Theseactiv-itiesincludecontactswithteachersandmentalhealthconsultantsandnon…face-to-facecontactwithparentsandpatients.Itwouldbehelpfulforcli-nicianstodocumentthenonreim-bursedeffortsandforthenationalAAP,statechapters,andclinicianstocontinuetotrytomakethird-partypay-ersunderstandtheneedfortheseef-fortsandprovidecompensationforthisappropriatecare.COMPLEMENTARYANDUNPROVENFamiliesofchildren/adolescentswithADHDincreasinglyaskaboutcomple-FROMTHEAMERICANACADEMYOFPEDIATRICS mentaryandalternativetherapiesforADHD.Suchtherapiesmightincludelargedosesofvitamins,essentialfattyacids,andotherdietaryalterations;chelation;andelectroencephalo-graphic(EEG)biofeedback.Todate,thereisinsuf“cientevidencetodeter-minewhetherthesetherapiesleadtochangesincoresymptomsofADHDorfunction,andformanyofthem,thereislimitedinformationabouttheirsafety.Forthesereasons,thesethera-piescannotberecommended.Sometherapies,chelation,andmegavita-minshavebeenproventocausesomeadverseeffectsandarePhysicianscanplayaconstructiveroleinhelpingfamiliesmakethoughtfultreatmentchoicesbyreviewingthestatedgoalsoreffectsclaimedforagiventreatment;thestateofevidencetosupportordiscourageuseofthetreatment;andknownorpotentialad-verseeffects.Physiciansshoulden-couragefamiliesthatwishtopursuethesetreatmentstotry1interventionatatime,choosetargetgoalstheywilluse,monitorcoresymptomstomea-sureef“cacy,andchooseatimeframeinwhichtheyanticipatethechangestooccur.Familiesshouldalsobestronglyencouragedtocontinuetousethemoreevidence-basedinterventionsatthesametimethattheyareexploringcomplementaryandalternativeCliniciansshouldrespectfamiliesin-terestsandpreferenceswhiletheyad-dressandanswerquestionsaboutcomplementaryandunproventhera-piestopreserveandenhancetheclini-cian/familyrelationship.Inaddition,primarycarecliniciansshouldknowaboutadditionaltherapiesthatfami-liesmightbeadministeringtoade-quatelymonitorfordruginteractions.Parentsandchildren/adolescentswhodonotfeelthattheirchoicesinhealthcarearerespectedbytheirprimarycareclinicianmightbelesslikelytocommunicateaboutcomplementaryoralternativetherapies.Furtherinformationaboutcomple-mentaryandothertherapiespro-mot

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