--- name: managing-attention-deficit-disorders language: en description: Structures ADHD evaluation in children with behavioral rating scales and medication trials. Use when evaluating pediatric ADHD, interpreting Vanderbilt/Conners scales, or managing stimulant therapy. tags: - management - pediatrics - valuation metadata: author: casemark practice_areas: - Pediatrics - Neonatology - Adolescent Medicine document_types: - Management Report skill_modes: - Management - Coordination --- # Managing Attention Deficit Disorders Structures the evaluation, diagnosis, and multimodal management of Attention-Deficit/Hyperactivity Disorder (ADHD) in children ages 4-18 using the AAP 2019 Clinical Practice Guideline, DSM-5 criteria, Vanderbilt Assessment Scales, evidence-based medication titration, and behavioral therapy coordination. ## Why This Skill Exists ADHD is the most commonly diagnosed neurobehavioral disorder of childhood, affecting approximately 9.4% of U.S. children ages 2-17. Despite high prevalence, it is both overdiagnosed (in populations with access) and underdiagnosed (in girls, minorities, and underserved communities). The AAP 2019 guideline mandates structured diagnostic criteria with multi-informant rating scales, age-stratified treatment recommendations, and systematic titration protocols. This skill enforces the guideline-based diagnostic pathway and treatment algorithm to prevent both missed diagnoses and inappropriate stimulant prescribing. --- ## Checkpoint A — Intake Verification ### Required Intake Questions 1. What is the child's age (4-18 for AAP guideline application)? 2. What are the primary concerns (inattention, hyperactivity, impulsivity, or combination)? 3. In which settings do symptoms occur (home, school, social, sports)? 4. When did symptoms first appear (must be present before age 12 per DSM-5)? 5. Are there academic problems (grades, IEP/504, retention)? 6. Is there a family history of ADHD, mood disorders, anxiety, or substance use? 7. Are there symptoms of comorbid conditions (anxiety, depression, ODD, learning disability, tic disorder, ASD)? 8. What is the child's sleep pattern (sleep deprivation mimics ADHD)? 9. Has the child had vision and hearing screening? 10. Has the child been previously treated with medication for ADHD? What was the response? ### Required Documents - Completed Vanderbilt Assessment Scales — Parent form AND Teacher form (or Conners-3, SNAP-IV) - Academic records (report cards, standardized test scores, teacher comments) - IEP/504 plan if applicable - Developmental history - Prior psychoeducational or neuropsychological testing (if done) - Vision and hearing screening results > DSM-5 requires symptoms in ≥ 2 settings. Teacher input is essential — do not diagnose ADHD without information from the school setting. --- ## Step 1 — DSM-5 Diagnostic Criteria ### Diagnostic Requirements To diagnose ADHD, ALL of the following must be present: 1. **Symptom threshold**: ≥ 6 of 9 inattention symptoms AND/OR ≥ 6 of 9 hyperactivity-impulsivity symptoms (for age ≥ 17: ≥ 5 in either domain) 2. **Duration**: symptoms present for ≥ 6 months 3. **Age of onset**: several symptoms present before age 12 4. **Pervasiveness**: symptoms present in ≥ 2 settings (home + school) 5. **Impairment**: clear evidence that symptoms interfere with functioning 6. **Exclusion**: not better explained by another mental disorder ### ADHD Presentation Types | Presentation | Criteria | |-------------|---------| | Predominantly inattentive | ≥ 6/9 inattention; < 6/9 H-I | | Predominantly hyperactive-impulsive | < 6/9 inattention; ≥ 6/9 H-I | | Combined | ≥ 6/9 in both domains | ### Inattention Symptoms (9) 1. Fails to give close attention to details / careless mistakes 2. Difficulty sustaining attention in tasks or play 3. Does not seem to listen when spoken to directly 4. Does not follow through on instructions / fails to finish tasks 5. Difficulty organizing tasks and activities 6. Avoids or is reluctant to engage in tasks requiring sustained mental effort 7. Loses things necessary for tasks 8. Easily distracted by extraneous stimuli 9. Forgetful in daily activities ### Hyperactivity-Impulsivity Symptoms (9) 1. Fidgets with hands/feet or squirms in seat 2. Leaves seat when remaining seated is expected 3. Runs about or climbs in inappropriate situations 4. Unable to play or engage in leisure activities quietly 5. "On the go" / acts as if "driven by a motor" 6. Talks excessively 7. Blurts out answers before questions are completed 8. Difficulty waiting turn 9. Interrupts or intrudes on others --- ## Step 2 — Vanderbilt Assessment Scale Interpretation ### Parent Vanderbilt (NICHQ Vanderbilt Assessment Scale — Parent Informant) - 55 items covering: inattention (9 items), hyperactivity/impulsivity (9 items), ODD (8 items), conduct disorder (14 items), anxiety/depression (7 items), and performance (8 items) - Symptom scoring: 0 = Never, 1 = Occasionally, 2 = Often, 3 = Very Often - Symptom is "positive" if scored 2 (Often) or 3 (Very Often) - ADHD screen positive: ≥ 6 of 9 inattention AND/OR ≥ 6 of 9 H-I items scored ≥ 2 - Performance impairment: ≥ 1 performance item scored 4 or 5 (somewhat/problematic) ### Teacher Vanderbilt (NICHQ Vanderbilt Assessment Scale — Teacher Informant) - 43 items: inattention (9), H-I (9), ODD/conduct (10), anxiety/depression (7), academic performance (3), classroom behavior (5) - Same scoring and threshold criteria as parent form - Academic performance: scored 1-5 (excellent to problematic) ### Concordance Analysis - Both parent AND teacher must show symptom endorsement for ADHD diagnosis - If only one setting endorses symptoms: investigate setting-specific factors (classroom structure, teacher expectations, home environment) - If discordant: consider alternative diagnoses (anxiety, learning disability, trauma) ### Comorbidity Screening (Built Into Vanderbilt) - ODD screen: ≥ 4 of 8 items scored ≥ 2 + performance impairment - Conduct disorder screen: ≥ 3 of 14 items scored ≥ 2 + performance impairment - Anxiety/depression screen: ≥ 3 of 7 items scored ≥ 2 + performance impairment → warrants formal evaluation --- ## Step 3 — Age-Stratified Treatment (AAP 2019) ### Ages 4-5 (Preschool) - **First-line**: parent-administered behavior therapy (evidence-based parent training programs) - **Medication**: methylphenidate may be prescribed if behavioral therapy is insufficient and symptoms cause moderate-to-severe functional impairment - Avoid amphetamines as first-line in this age group (less evidence) ### Ages 6-11 (School-Age) - **First-line**: FDA-approved medication for ADHD AND/OR evidence-based behavioral therapy (preferably both) - AAP recommends medication + behavioral therapy as optimal combined treatment - Teacher-delivered behavioral strategies (daily report card, classroom accommodations) ### Ages 12-18 (Adolescent) - **First-line**: FDA-approved medication with assent from the adolescent - Behavioral therapy should be offered, but medication is the primary treatment - Address driving safety, substance use risk, and organizational skills - Discuss medication continuity through transitions (college, employment) --- ## Step 4 — Medication Management ### Stimulant Medications (First-Line) #### Methylphenidate Formulations | Formulation | Brand Examples | Duration | Starting Dose | |-------------|---------------|----------|---------------| | Immediate-release | Ritalin | 3-4 hours | 5 mg BID-TID | | Extended-release (OROS) | Concerta | 10-12 hours | 18 mg QAM | | Extended-release (beaded) | Ritalin LA, Aptensio XR | 8-10 hours | 10-20 mg QAM | | Transdermal patch | Daytrana | 10-12 hours | 10 mg/9 hr patch | | Liquid | Quillivant XR | 10-12 hours | 20 mg QAM | #### Amphetamine Formulations | Formulation | Brand Examples | Duration | Starting Dose | |-------------|---------------|----------|---------------| | Mixed amphetamine salts IR | Adderall | 4-6 hours | 5 mg QD-BID | | Mixed amphetamine salts XR | Adderall XR | 10-12 hours | 5-10 mg QAM | | Lisdexamfetamine | Vyvanse | 12-14 hours | 20-30 mg QAM | | Dextroamphetamine | Dexedrine | 4-6 hours | 2.5-5 mg BID | ### Titration Protocol 1. Start at the lowest recommended dose 2. Titrate every 1-2 weeks based on response and side effects 3. Use Vanderbilt Follow-Up scales (parent + teacher) to assess response 4. Target: symptom reduction to < 6 positive items in affected domains + improved performance 5. If one stimulant class fails (methylphenidate): switch to amphetamine class (and vice versa) before moving to non-stimulant ### Non-Stimulant Medications (Second-Line) | Medication | Class | Starting Dose | Notes | |-----------|-------|---------------|-------| | Atomoxetine | NRI | 0.5 mg/kg/day × 3 days → 1.2 mg/kg/day | Onset 4-6 weeks; FDA black box: suicidal ideation monitoring | | Guanfacine XR | Alpha-2 agonist | 1 mg QHS | Sedation, hypotension; do not abruptly discontinue | | Clonidine XR | Alpha-2 agonist | 0.1 mg QHS | Similar to guanfacine; also treats tics | | Viloxazine XR | NRI | 100 mg QAM (6-11y); 200 mg QAM (12+) | Newer; less data on long-term outcomes | ### Side Effect Monitoring - **Every visit**: weight, height, heart rate, blood pressure - **Appetite suppression**: most common side effect; counsel on high-calorie breakfast, after-medication meals, bedtime snacks - **Growth**: plot height and weight on growth chart at every visit; calculate height velocity annually; temporary growth deceleration is common - **Sleep**: stimulants may cause insomnia; consider earlier dosing, shorter-acting formulation, or melatonin adjunct - **Cardiovascular**: routine ECG NOT recommended for healthy children; obtain ECG only if cardiac history, family history of sudden death, or abnormal cardiac exam - **Tics**: stimulants may unmask but generally do not cause tics; tics are not an absolute contraindication - **Mood/behavior**: monitor for rebound irritability, emotional lability, new anxiety --- ## Step 5 — Behavioral and Academic Interventions ### Evidence-Based Behavioral Therapy - **Parent training programs**: Triple P, Incredible Years, Parent-Child Interaction Therapy (PCIT) - **Classroom interventions**: daily report card (DRC), preferential seating, extended time, reduced homework load, frequent breaks - **Social skills groups**: peer interaction training (for children with social impairment) - **Organizational skills training**: for ages 8+ (homework routines, planner use, time management) ### School Accommodations - Section 504 plan: ADHD qualifies as a disability under Section 504 - IEP: if ADHD causes specific learning disability requiring specialized instruction (under IDEA category "Other Health Impairment") - Common accommodations: extended time on tests, preferential seating, reduced homework, movement breaks, behavior intervention plan --- ## Checkpoint B — ADHD Management Review - [ ] DSM-5 criteria systematically evaluated and documented - [ ] Symptoms confirmed in ≥ 2 settings (parent + teacher Vanderbilt) - [ ] ADHD presentation specified (inattentive, H-I, combined) - [ ] Comorbidities screened (ODD, conduct, anxiety, depression, learning disability) - [ ] Age-appropriate treatment initiated (behavioral therapy for 4-5; medication ± behavioral for 6+) - [ ] Medication selected, dose documented, titration plan specified - [ ] Side effect monitoring documented (weight, height, HR, BP) - [ ] Follow-up Vanderbilt scales collected from parent AND teacher - [ ] School accommodations addressed (504 or IEP discussion) - [ ] Driving safety discussed (if adolescent) - [ ] All [VERIFY] flags resolved or escalated --- ## Quality Audit | Item | Requirement | Pass? | |------|-------------|-------| | Multi-informant data | Parent AND teacher Vanderbilt/Conners completed | | | DSM-5 compliance | All 6 diagnostic criteria explicitly addressed | | | Presentation specified | Inattentive / H-I / Combined documented | | | Comorbidity screen | ODD, anxiety/depression at minimum screened | | | Age-appropriate Tx | Behavioral therapy first for 4-5; combined for 6+ | | | Titration plan | Starting dose, target, timeline for reassessment | | | Growth monitoring | Weight and height plotted at each medication visit | | | Vital signs | HR and BP documented at each medication visit | | | School coordination | 504/IEP addressed or discussed | | | No unexplained [VERIFY] tags | All flagged items resolved or escalated | | --- ## Guidelines - Follow AAP 2019 Clinical Practice Guideline: Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents - Use DSM-5 criteria for ADHD diagnosis (APA 2013) - NICHQ Vanderbilt Assessment Scales: recommended by AAP for initial evaluation and follow-up monitoring - Stimulant titration: start low, go slow, use rating scales to measure response objectively - MTA study (Multimodal Treatment Study of ADHD): combined medication + behavioral therapy superior to either alone for school-age children - AAP: no routine ECG for ADHD medication initiation in healthy children without cardiac risk factors - FDA black box: atomoxetine — monitor for suicidal ideation, particularly in first months - Alpha-2 agonists: do not abruptly discontinue (rebound hypertension risk) - Substance abuse: treated ADHD reduces substance abuse risk; untreated ADHD increases it - ADHD is a chronic condition: treatment should not be discontinued without structured medication holiday and reassessment - This skill produces clinical documentation; it does not replace clinical judgment