Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in

1. TM Prepared for your next patient. Clinical Practice Guideline forthe Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents Mark L. Wolraich, MD, FAAP CMRI/Shaun Walters Professor of Pediatrics University of Oklahoma Health Sciences Center

2. Disclaimers • Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics. • Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenter has complete and independent control over the planning and content of the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenter’s comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.

3. Disclosures Consultant with: • Lilly • Shire • Shinogi • NextWave

4. Learning Objectives • Participants will be able to report on the major changes in the revised attention-deficit/hyperactivity disorder (ADHD) guideline. • Participants will be able to obtain and use appropriate behavior rating scales. • Participants will be able to describe the importance of considering ADHD as a chronic condition. • Participants will be aware of the variations in treatment recommended for preschool age children and adolescents.

6. ADHD Guideline Recommendations The primary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. B/strong recommendation

7. Prevalence of ADHD in Children Centers for Disease Control and Prevention/National Health Care Surveys, 1997–2006

8. Prevalence and Medication Use ADHD prev ADHD noton meds ADHD diagnosedon meds ADHDon meds

9. ADHD Guideline Recommendations • To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)criteria have been met (including documentation of impairment in more than 1 major setting) with information obtained primarily from parents/guardians, teachers, and other school and mental health clinicians involved in the child’s care. The primary care clinician should also rule out any alternative cause. B/strong recommendation

10. Evaluation • Identify core symptoms. • Assess impairment. • Identify possible underlying or alternative causes. • Identify co-occurring (co-morbid) conditions.

11. DSM-IV Core Symptoms of Inattention Manifestations of the following symptoms must occur often:* • Inattention • Careless • Difficulty sustaining attention in activity • Doesn’t listen • No follow-through • Avoids/dislikes tasks requiring sustained mental effort • Can’t organize • Loses important items • Easily distractible • Forgetful in daily activities *Must have 6 or more symptoms for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Arlington, VA: American Psychiatric Association; 2000

12. DSM-IV Core Symptoms of Hyperactivity-Impulsivity Manifestations of the following symptoms must occur often:* • Hyperactivity • Squirms and fidgets • Can’t stay seated • Runs/climbs excessively • Can’t play/work quietly • “On the go”/“driven by a motor” • Talks excessively Impulsivity • Blurts out answers • Can’t wait turn • Intrudes/interrupts others *Must have 6 or more symptoms for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Arlington, VA: American Psychiatric Association; 2000

13. Assess Function • Academic performance • Peer relations • Sibling relations • Parent relations • Community activities

14. Clinical Global Impression Scale

15. DSM-IV ADHD Diagnostic Criteria American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth edition. Arlington, VA: American Psychiatric Association; 2000 • List of core symptoms must be present for past 6 months. • Some symptoms need to be present before 7 years of age. • Some impairment from symptoms must be present in 2 or more settings (eg, school and home). • Significant impairment (social, academic, or occupational) must be present. • Other mental disorders need to be excluded as the cause of the core symptoms.

16. Inattention or Hyperactive/Impulsive Problems American Academy of Pediatrics. In: Wolraich ML, Felice ME, Drotar D. The Classification of Child and Adolescent Mental Diagnosis in Primary Care. Elk Grove Village, IL: American Academy of Pediatrics; 1996 • Children who do not meet the criteria of ADHD still may have some symptoms of inattention and/or hyperactivity/impulsivity fitting the category in the Diagnostic and Statistical Manual for Primary Care (DSM-PC) of inattention and/or hyperactivity/impulsivity. Use of the chronic illness model and behavioral interventions are appropriate, but medications are not.

17. Preschool Age Diagnostic Issues Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–1293 • The same criteria are pertinent for preschool age children, but it is more difficult to find qualified observers of these children. • Enroll the child in a program and/or have the parents participate in a parent training program.

18. Adolescent Diagnostic Issues Wolraich ML, Wibbelsman CJ, Brown TE, et al. Attention-deficit/hyperactivity disorder in adolescents: a review of the diagnosis, treatment and clinical implications. Pediatrics. 2005;115:1734–1746 • It is much more difficult to get adequate observers, as both parents and teachers have less opportunity to observe. • The risk of substance abuse is higher and must be ruled out before a diagnosis can be made. • The occurrence of co-morbid conditions, particularly anxiety or depression, is more frequent.

19. Diagnostic Process • Use of ADHD specific rating scales is a clinical option in the evaluation of ADHD. • Use of broad-band rating scales is not recommended in diagnosing ADHD although they may be useful for evaluating for coexisting conditions.

21. Websites for the Vanderbilt Scales • The University of Oklahoma College of Medicine http://www.idi.ouhsc.edu/body.cfm?id=4779 • American Academy of Pediatrics - Pediatric Care Onlinehttps://www.pediatriccareonline.org/pco/ub/index/Forms-Tools/Keywords/N/NICHQ

22. ADHD Guideline Recommendations Evaluation of a child for ADHD should include assessment for coexisting conditions, including emotional, developmental, and physical. B/strong recommendation

23. Co-morbidity:Conditions Commonly Co-occurring with ADHD • Disruptive behavior disorders • Oppositional defiant disorder • Conduct disorder • Depressive disorders • Anxiety disorders • Cognitive disorders • Learning disabilities • Language disorders • Motor disorders • Developmental coordination disorder • Tic disorders (Tourette's)

24. ADHD Guideline Recommendations • The primary care clinician should establish a treatment program that recognizes ADHD as a chronic condition and a child with ADHD as a child/adolescent with special health care needs who needs a medical home. B/strong recommendation

25. Methylphenidate therapy bout length by patient age Miller AR, Lalonde CE, McGrail KM. Children’s persistence with methylphenidate therapy: a population-based study. Can J Psychiatry. 2004;49(11):761–768

26. Treating ADHD as a Chronic Condition • Educate parents and patients about ADHD. • Develop a partnership with the family. • Develop a management plan with specific targeted goals. • Include the teachers if at all possible. • Requires ongoing monitoring and anticipation of developmental changes.

27. ADHD Guideline Recommendations • Recommendations for treatment of children and youth with ADHD vary depending on the patient’s age:

28. Preschool-aged Children(4–5 Years of Age) • and • May prescribe methylphenidate if the behavior interventions do not provide significant improvement and there is moderate-to-severe continuing disturbance in the child’s function. B/recommendation Prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment. A/strong recommendation

29. Preschool Age Treatment Issues Greenhill L, Kollins S, Abikoff H, et al. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with ADHD. J Am Acad Child Adolesc Psychiatry. 2006;45(11):1284–1293 • While stimulant medications are appropriate for preschool age children based on recent research, given that a third of the children in a multi-site study improved on behavioral interventions alone, it is more appropriate to initiate a parent training program first before utilizing medication and only treat the more severe cases. • Preschool age children frequently have a slower metabolism of the medications and can start at a lower dose and titrated at a slower rate.

30. Elementary School-aged Children(6–11 Years of Age) and/or Evidence-based parent- and/or teacher-administered behavior therapy as treatment for ADHD. Preferably both. B/recommendation Prescribe FDA-approved medications for ADHD. A/strong recommendation

31. Adolescents (12–18 Years of Age) and May prescribe behavior therapy as treatment for ADHD. C/recommendation Preferably both. Prescribe FDA-approved medications for ADHD with the assent of the adolescent. A/strong recommendation

32. Non-Stimulants • Atomoxetine is a highly specific norepinephrine reuptake inhibitor. • Extended release guanfacine and clonidine are alpha 2 adrenergic agents.

33. ADHD Guideline Recommendations The primary care clinician should titrate doses of medication for ADHD to achieve maximum benefit with minimum adverse effects. B/strong recommendation

34. Summary • Children from preschool age through adolescent age can be diagnosed and treated for ADHD. • Both medications (stimulants, selective norepinephrine reuptake inhibitors and alpha adreneric agents) and behavior therapy are effective and safe treatments for ADHD. • Effective treatments require appropriate titration and ongoing monitoring to remain effective.

35. Caring for Children With ADHDA Resource Toolkit for Clinicians, 2nd Edition This comprehensive ADHD resource provides a full set of tools for assessment and diagnosis, treatment and medication, monitoring and follow-up, parent education and support, and coding and payment. Included are more than 40 practice-tested tools—many in English and Spanish—on one convenient CD-ROM. The ADHD toolkit components have been evaluated and refined based on input from the American Academy of Pediatrics Quality Improvement Innovation Network (QuIIN). For more information or to order visit the AAP bookstore at http://tinyurl.aap.org/pub169531.

36. Additional ADHD Resources on Pediatric Care Online (www.pediatriccareonline.org) • Forms & Tools https://www.pediatriccareonline.org/pco/ub/index/Forms-Tools/Keywords/A/ADHD • Patient Handoutshttps://www.pediatriccareonline.org/pco/ub/index/Patient_Handouts_AAP/Keywords/A/ADHD • AAP Textbook of Pediatric Carehttps://www.pediatriccareonline.org/pco/ub/index/AAP-Textbook-of-Pediatric-Care/Topics/A • Point-of-Care Quick Referencehttps://www.pediatriccareonline.org/pco/ub/index/Point-of-Care-Quick-Reference/Topics/A

37. For more information… On this topic and a host of other topics, visit:www.pediatriccareonline.orgPediatric Care Onlineis a convenient electronic resource for immediate expert help with virtually every pediatric clinical information need. Must-have resources are included in a comprehensive reference library and time-saving clinical tools. Haven't activated your Pediatric Care Online trial subscription yet?It's quick and easy: simply follow the steps on the back of the cardyou received from your Mead Johnson representative. Haven't received your free trial card?Contact your Mead Johnson representative or call 888/363-2362 today.