By: Jenna Schmidt

1. By: Jenna Schmidt

2. Attention Deficit Hyperactivity Disorder • ADHD is caused by a chemical imbalance in the brain that affects the parts controlling attention, concentration and impulsivity. This means a child’s behavior can be anything from being ‘very dreamy’ (or unable to pay attention) through to being ‘always on the go’ (or hyperactive). • A person with ADHD has difficulty filtering out all the information coming into his brain, so he’s easily distracted, tends to respond before he has considered things properly and doesn’t know when to stop. • A child with ADHD will take longer to settle and concentrate than a child without, and may have problems following instructions.

3. ADHD Continued… • Children with ADHD often have above-average intelligence but find it hard to learn. They often also have problems socializing. • The condition is long term and can continue through adult life. There is a genetic component, and children with ADHD often have relatives (frequently male) with ADHD. • It isn’t caused by bad parenting, but a child’s surroundings and support can affect how severe the symptoms are and how well he can learn to deal with them.

4. Past Names For ADHD • ADHD was first described by George Still in 1902. He called it ‘morbid defect of moral control’. It’s also been called: • minimal brain damage (1930). • minimal brain dysfunction (1960). • hyperkinetic reaction of childhood (1968). • attention deficit disorder (ADD) with or without hyperactivity (1980). • Since 1987, it has been known as ADHD or attention deficit hyperactivity disorder. The World Health Organization brought out a second definition in 1992, ‘hyperkinetic disorder’, a narrower definition than ADHD and comprises only the more serious cases.

5. DSM IV TR- 3 types • ADHD combined type: this is the most common type, and means the child has six or more symptoms in each category. • ADHD predominantly inattentive type: this means the child has six or more inattention symptoms but fewer than six hyperactivity-impulsivity symptoms. • ADHD predominantly hyperactive-impulsive type: this is the least common type and means that the child has six or more hyperactivity-impulsivity symptoms but fewer than six inattention symptoms

6. Symptoms of ADHD Inattention Type: • (a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities (b) often has difficulty sustaining attention in tasks or play activities (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions) (e) often has difficulty organising tasks and activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework). (g) often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools) (h) is often easily distracted by extraneous stimuli (i) is often forgetful in daily activities • 6 (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level

7. Symptoms of ADHD Hyperactivity Type: • (a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often "on the go" or often acts as if "driven by a motor" (f) often talks excessively

8. Symptoms of ADHD Impulsivity Type: • (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g. butts into conversations or games) • B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. • C. Some impairment from the symptoms is present in two or more settings (e.g. at school [or work] and at home). • D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. • E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)

9. Population • According to the National Institute of Mental Health two to three percent of children have ADHD.  This means that in a typical classroom at least one child is ADHD.  The NIMH estimates that about 2 million children in the United States have ADHD. • A neurologist by the name Dr. Fred Baughman estimated that 500,000 children were diagnosed with ADHD in 1985 and he estimates that there are now 5 to 7 million children with this diagnosis. 

10. Treatment Options • medication • behavioral therapy • psychotherapy • educational techniques. The most effective way to treat ADHD is a combination of these options.

11. Medication Treatment Some Psychostimulants Include: • Methylphenidate (Ritalin, Concerta) • Dextroamphetamine/amphetamine (Adderall) • Dextroamphetamine (Dexedrine) • Atomoxetine (Strattera) – a non-stimulant with similar effective action is also used. Other Non-Stimulant Medications Include: • imipramine and bupropion (Brand name: Wellbutrin) (both antidepressants) • clonidine, which may help children with ADHD who have aggressive antisocial behavior.

12. Behavioral Therapy Treatment teachers and parents learn strategies such as: • CBT- contingency management procedures to deal with children’s behavior. The strategy includes: • token reward system • timeouts.

13. Psychotherapy Treatment • Older children and adults suffering from ADHD are allowed to talk and discuss the issues that trouble them, explore negative behavioral patterns and permitted to learn the ways to deal with their symptoms.

14. Educational Techniques • Support Groups- These groups offer a net work of social support, information and education to adults and children suffering from ADHD and their parents, friends and relatives. • Social Skills Training- This helps children to learn appropriate social behavior. • Parent Skills Training- This helps the parents to develop ways to understand and guide the child in his day-to-day life. Best results are be obtained with teachers, parents and therapists or physicians working in teams.

15. Present Research • Virtual Reality Study for Young males ages 12–16 (Fitzgerald) • Genetics of ADHD (Kollins) • Follow-up of the Multimodel Treatment Study of ADHD Children (MTA) - (Murray/Wells) • The MTA Study

16. ADHD Researchers • Russell Barkley, PhD, • Rutter, M. & Smith, D. (1995) • Kewely, G. (1998) • Hinshaw, S. (1994) • Hill, P., & Cameron, M. (1999) • Farrington, D. (1990) • Cooper, P. (1997) • Angold, A., Costello, E., & Erkanli, A. (1999).

17. Assessment Instruments • The most important diagnostic tool is the clinical interview. • A thorough medical examination is important to identify other conditions that may be responsible for symptoms that coexist with ADHD and require treatment. • Various psychological tests are used to diagnose ADHD; The Conners' Parent and Teacher Rating Scale (for children) and the Brown Attention Deficit Disorder Scale (BADDS) for teens and adults are useful tools for diagnosis of ADHD. • Impulsivity and inattention are assessed with the Conners Continuous Performance Test (CPT), the Integrated Visual and Auditory (IVA) CPT, or both. The Nadeau/Quinn/Littman ADHD Self-Rating Scale for Girls is a part of the assessment for all girls (3).

18. Outcomes • Several studies have followed children with ADHD/ADD into adulthood. Although these results vary from study to study, it appears that about 50% continue to show evidence of the disorder in adulthood, especially attention problems and impulsivity. Almost a third will have dropped out of high school, and only 5% complete a university degree compared to 40% of their peers. Approximately 25% have developed chronic patterns of anti-social behavior. Clearly, for many children with ADHD/ADD, this disorder is a chronic condition that can adversely affect their development over many, many years. (National Institute of Mental Health)

19. Evidence Based Practice • The National Institute for Mental Health concluded that “long-term combination treatments and the medication-management alone were superior to intensive behavioral treatment and routine community treatment. And in some areas—anxiety, academic performance, oppositionality, parent-child relations, and social skills—the combined treatment was usually superior. Another advantage of combined treatment was that children could be successfully treated with lower doses of medicine, compared with the medication-only group”.  Most professionals agree that this intervention should be available to all parents of kids with ADHD.

20. Evidence Based Practice Cont… • The NIMH found that the combined treatment (medication management with behavior therapy), compared with medication alone, offered improved scores on academic measures, measures of conduct, and some specific ADHD symptoms

21. Prior Authorization Criteria: • Dose not to exceed 1.5 times the FDA approved maximum. • No concurrent use of multiple products from this category, ie, Strattera + Stimulant, Methylphenidate + Amphetamine • Prior authorization is required for all stimulants for adults age 21 and older. • Gaining prior authorization for prescription medication requires phones calls, faxes and request forms, which often can be time-consuming. Fortunately for both providers and patients, help is on the way to streamline and accelerate this process. • Prior authorization requires physicians to show the medical necessity for a patient to receive a particular medication.

22. EBP & PA Websites / forms • Evidence Based Practice: http://www.cde.state.co.us/cdesped/download/pdf/FF-ADHD.pdf • Prior Authorization Forms: www.okhca.org https://www.navitus.com/Prior%20Authorization%20Forms/ADHD%20Stimulants%20-%20Arizona.pdf http://www.dhhs.state.nh.us/NR/rdonlyres/e2emyzsepqvzbgjakmvxdxtm5l6zsw2b6qfjzcuzujpyjffyew2f3cqsi77f2ywlhnx2i4pnrsyfo3voo3injrlhvnc/CNSADHD+5-1.pdf https://tnm.rxportal.sxc.com/rxclaim/TNM/TC%20PA%20Request%20Form%20(Provigil).pdf

23. Organizations & Websites • Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)Phone: (800) 233-4050http://chadd.org • Attention Deficit Disorder Association (ADDA)Phone: (856) 439-9099http://www.add.org/ • American Psychiatric AssociationPhone: (888) 357-7924http://www.psych.org/ • American Psychological AssociationPhone: (800) 374-2721http://www.apa.org/

24. Resources • U.S. Department of Education. (2003). Identifying and Colorado Advisory Network implementing educational practices supported by (303) 721-0648 rigorous evidence: A user friendly guide. Email: canindiv@aol.com Washington, D.C.: Web: www.localsonsors.com/denver/can • Promising Practices Network: http://www.promisingpractices.net/ Center for Attention Deficit 5835 Lehman Drive • What Works Clearinghouse: http://www.w-w-c.org/ Colorado Springs, CO 80918 (719) 531-9211 • Children and Adults with Attention Disorders (CHADD) 499 N.W. 70 Ave. Suite 101 National Information Center for Children Plantation, FL 33317 and Youth with Disabilities (800) 233-4050 Rocky MT. CHADD (303) 761-5024 P.O. Box 1492 Web: www.chadd.org Washington, DC 20013 (800) 695-0285 (202) 884-8200 • Parent Education and Assistance for Kids (PEAK) Email: mail@aed.org 611 N. Weber, Suite 200 Web: www.nichcy.org Colorado Springs, CO 80903 (800) 284-0251 (719) 531-9400 National Attention Deficit Disorder Assoc. Web: www.peakparent.org 1788 Second Street, Suite 200 Highland Park, IL 60035 • Parent to Parent of Colorado 847-423-ADDA 2200 S. Jasmine Street Email: mail@add.org Denver, CO 80222 Web: www.add.org (877) 472-7201 (toll free) (719) 336-2389

25. Resources Continued… Books: • Brown, T.E. (Ed.) (2000). Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Washington, DC: American Psychiatric Press. • Goldstein, S., & Teeter Ellison, A. (Eds.) (2002). Clinician's guide to adult AD/HD: Assessment and intervention. New York: Academic Press. • Murphy, K.R., & Gordon, M. (1998). Assessment of adults with AD/HD. In Barkley, R. (Ed.) Attention-Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment. (pp. 345-369). New York: Guilford Press.

26. Discussing Diagnosis with Family • Medications, including side effects of treatment and side effects of no treatment along with dosage Other interesting facts: • 60-80% of children with ADHD continue to have symptoms in adolescence • 4-12% of school age children are thought to have ADHD • Stimulants can cause unpredictable effects on motor tics, which transiently occur in 15-30% of children taking stimulants, but the 'presence of tics before or during medical management of ADHD is not an absolute contradindication to the use of stimulant medications.'

27. Other Information to discuss with Parents: • Stimulants include different formulations of methylphenidate: • short acting, such as Ritalin and Focalin, with a duration of 3-5 hours • intermediate acting, such as Ritalin SR, Metadate ER, and Methylin ER, with a duration of 3-8 hours • long acting, such as Concerta, Rilatin LA and Metadate CD, with a duration of 8-12 hours and which can be used just once a day • The other type of stimulant includes different formulations of amphetamine: • short acting, such as Dexedrine and Dextrostat, with a duration of 4-6 hours intermediate acting, such as Adderall and Dexedrine spansule, with a duration of 6-8 hours • long acting, such as Adderall-XR

28. References • Anastopoulos, A. (1999). ADHD. In child and adolescent psychological disorders: A comprehensive textbook. Oxford: Oxford University Press. • Angold, A., Costello, E., & Erkanli, A. (1999). Cormorbidity. Journal of Child Psychology and Psychiatry, 40(1), 57-88. • American Psychiatric Association (APA) (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: APA Press. • Barkley, R. (1990). ADHD: A handbook for diagnosis and treatment. New York: Guliford Press. • Cooper, P. (1997). The reality and hyperreality of adhd: an educational and cultural analysis. The Association of Workers for Children with Emotional and Behavioral Difficulties: East Sutton: South London Press. • Farrington, D. (1990). Implications of criminal career research for the prevention of offending. The Journal of Adolescence, 13, 93-113. • Hill, P., & Cameron, M. (1999). Recognizing hyperactivity: A guide for the cautious clinician. Child Psychology and Psychiatry Review, 4(2), 50-60. • Hinshaw, S. (1994). Attention deficits and hyperactivity in children. New York: Sage Press. • Kewely, G. (1998). Medical Aspects of Assessment and Treatment of Children with ADHD. In ADHD: Educational, medical and cultural issues, Cooper, P., Ideus, K. (eds). Association of Workers for Children with EBD. East Sutton: South London Press. • Levy, F. & Hay, D. (2001). Attention, genes and adhd. Hove: Brunner-Routledge Press. • National Institute of Clinical Excellence (NICE) 2000. Guidance on the use of methylphenidate for adhd. London: NICE Press. • Palmer, E., & Finger, S. (2001). An early description of ADHD: Dr. Alexander Crichton and mental restlessness. Child Psychology and Psychiatry Review, 6(2), 66-73. • Rutter, M. & Smith, D. (1995). Psychosocial disorders in young people. Chichester: Wiley Press. • Tannock, R. (1998). ADHD: Advances in cognitive, neurobiological and genetic research. Journal of Child Psychology and Psychiatry, 39(1), 65-99. • Thompson, R. (1993). The brain: A neuroscience primer. New York: Freeman Press. • Weiss, G. & Hectman, L. (1993). Hyperactive children grown up. New York: Guliford Press.