ADHD

adhd cdc

DSM 5 Shorthand Descriptions of Diagnosis: 

Attention Deficit Disorder-Hyperactivity Disorder (ADHD): developmentally inappropriate and persistent difficulty with inattention and/or hyperactivity with symptoms present in multiple settings.

Diagnosing  ADHD in Adults: ADHD often lasts into adulthood. To diagnose ADHD in adults and adolescents age 17 years or older, only 5 symptoms are needed instead of the 6 needed for younger children. Symptoms might look different at older ages. For example, in adults, hyperactivity may appear as extreme restlessness or wearing others out with their activity.

-Common Child Disorders DSM-5 Criteria

Plan of Care (Steps for Treating ADHD)

Side note: private practice or other clinics may not require these considerations but this post is primarily for treating ADHD in community settings:

  1. Make sure ADHD was formally diagnosed: A provider may see the s/s in the office but a formal diagnosis is made in a separate appointment, it minimally takes hours, and it’s very helpful before prescribing medications. It helps if there was prior treatment or a diagnosis, but I’m primarily talking about patients who don’t have an original diagnosis. There may be some politics involved but state insurance companies did not cover the medications, including the non-stimulants based on the (office visit) diagnosis/assessment alone. Stimulants cost $$$ out-of-pocket so to save you time and a headache, on the first appointment I usually write out a prescription for psychological testing (because that also costs hundreds of dollars out-of-pocket). I also do this for adults who claim they were on stimulants but don’t have paperwork, have never been diagnosed, or don’t have prior (recent/<2 years) evidence of using stimulants. This is how you will write it on a prescription pad in the open space area: F.90.1 psychological testing for IQ r/o ADHD. I also put “please fax results” to the clinic. I give the patient/family a list of places to go to (I have about 7) and explain that you must call whoever is willing to see you asap (to get the test completed by the next appointment). My collab physician believes these checks and balances are not needed or you can just use a screening tool (but these are not diagnostic). It seems like he thought I meant, we (NPs) can’t dx it ourselves, which wasn’t the case…of course, providers can diagnose psych disorders but overall times are changing and state insurance doesn’t want to cover stuff now more than ever. It’s like I need a day off just to handle pharmacy and prior auths! Besides and I hate to be brutally honest but doctors generally do NOT get as much flak or challenge as other care providers. People usually take what a physician says at face value, even if it’s lacking standards or a justification. I’m not saying my collab is incorrect but be mindful that stimulants are easily misused so you need a system to weed out the bad apples. -I also just wanted to add… because of the psychological testing, I was able to vouch for the kids that needed extra time in classes. Again, the testing isn’t mandatory but having significant reliable information is necessary.
  2. Run a report of stimulants/opioids prescribed: the main reason to get a report is to see consistency and make sure there are no conflicts. Again, this is part of your system to weed out the bad apples. If the person didn’t have a stimulant regimen in decades, then it’s questionable to suddenly start prescribing it, oh and insurance companies will question that as well. I had a lady not on her stimulant for only about 18 months due to having a baby and the insurance company STILL didn’t want to cover it until I explain all these factors why it was an appropriate reason for the gap. Plus running a report is usually mandatory in the EMR and state laws.
  3. Start Low and Go Slow: If I’m dealing with a child without prior medications, I usually prescribe the non-stimulants first.  If my patient is tiny (before puberty), I’ll use guanfacine and if the child is still super hyper or still need to calm down, I’ll use clonidine or increase the frequency of guanfacine. The main difference is primarily due to making sure the BP is not significantly affected. However, with tiny patients, I try to stay clear of stimulants or at least caution with amphetamines. Emphasize taking the dose with a meal and consider giving the stimulant (holiday) breaks like on non-school days to reduce the decrease in growth/weight concerns.
  4. Target Other Areas that WILL hinder Focus: In addition to the medication, educate about proper eating and activity habits. Treat mood symptoms and emphasize SLEEP. Restlessness will worsen the mood and focus, plus another s/e of stimulants is insomnia so I assess sleep as the 5th vital sign. Read more about treating sleep problems in kids.
  5. Extra considerations:  caution stimulant use with heart conditions but thankfully most kids grow out of stuff so just keep monitoring it. Look out for side effects, I have a kid on Adderall to treat his tics, a female that is experiencing tics that came from using Vyvanse, and another teenager who can control her tics and not on stimulants so treat tics and s/e on a case-by-case situation. Lastly, drug testing is a hit or miss for me, it should be done on everyone before prescribing but it’s usually not practical. Just FYI the methadone clinic drug tests weekly and you can request those results. Patients on probation also have to do regular drug testing so I can prescribe to them knowing that it shouldn’t be a huge risk. For my kids, I can also request past records so there are ways to get testing done outside the clinic but it requires extra work.
  6. Adderall vs Ritalin: according to most literature, amphetamines are the standard but if you’re concerned about tiny patients then methylphenidate or the non-stimulants may be a better option. You can still consider Adderall if it gave the best response but consider med breaks, low dosing, or short-acting formulas, so the s/e won’t be prolonged and again prioritize sleep, which is a completely different issue.
  7. What about the poor behavior?? sometimes stimulants will also improve the mood but if not, I usually go towards risperidone and aripiprazole because it’s a great option for micro/low dosing and it’s FDA approved for treating kids. But again, we are adding medications, side effects..etc. and this is why genetic testing comes in handy and should be done during the initial intake. What happens when the medications aren’t helping?  Which direction will the provider go next, should we increase the dose, switch the med, or start a mood stabilizer? Sometimes you just need to increase the dose but what if there are genetic interactions and you keep giving the same med… How much worse do things have to get? are you going to keep juggling meds around and hope for the best? so I just wanted to emphasize again why genetic testing is important because it can help improve outcomes. Plus, the family, your peers, and YOU yourself will start questioning your capabilities if things are not getting better. Improve the plan of care to avoid bigger problems.

About (Non) Stimulants

What are Stimulants? As the name suggests, stimulants increase alertness, attention, and energy, as well as elevate blood pressure, heart rate, and respiration (National Institute on Drug Abuse, 2014). Stimulant medications are often prescribed to treat children, adolescents, or adults diagnosed with ADHD.

Stimulants used to treat ADHD include from NIH:

Note: In 2002, the FDA approved the non-stimulant medication atomoxetine for use as a treatment for ADHD. Two other non-stimulant antihypertensive medications, clonidine, and guanfacine are also approved for the treatment of ADHD in children and adolescents. One of these non-stimulant medications is often tried first in a young person with ADHD, and if the response is insufficient, then a stimulant is prescribed.

Stimulants are also prescribed to treat other health conditions, including narcolepsy, and occasionally depression (especially in older or chronically medically ill people and in those who have not responded to other treatments).

How do people respond to stimulants?

Prescription stimulants have a calming and “focusing” effect on individuals with ADHD. Stimulant medications are safe when given under a doctor’s supervision. Some children taking them may feel slightly different or “funny.”

Some parents worry that stimulant medications may lead to drug abuse or dependence, but there is little evidence of this when they are used properly as prescribed. Additionally, research shows that teens with ADHD who took stimulant medications were less likely to abuse drugs than those who did not take stimulant medications.

What are the possible side effects of stimulants?

Stimulants may cause side effects. Most side effects are minor and disappear when dosage levels are lowered. The most common side effects include:

  • Difficulty falling asleep or staying asleep
  • Loss of appetite
  • Stomach pain
  • Headache

Less common side effects include:

  • Motor tics or verbal tics (sudden, repetitive movements or sounds)
  • Personality changes, such as appearing “flat” or without emotion

Stimulants may cause other side effects that are not included in the list above. To report any serious adverse effects associated with the use of stimulants, please contact the FDA MedWatch program using the contact information at the bottom of this page. For more information about the risks and side effects of each medication, please see Drugs@FDA.

–Read More About Common Medications

Additional Resources & Organizations

–Extra ADHD Resources

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