ADHD in the Primary Care Setting 3/16/2022

Attention-Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition that can impact children’s lives in many ways. Unidentified and untreated ADHD can cause difficulties at school, at home and can contribute to anxiety and mood symptoms. In 2019, The American Academy of Pediatrics published updated clinical guidelines for the diagnosis, and management of ADHD, recommended ADHD evaluation for any child with school and behavioral difficulties and outlined treatment guidelines. Recent studies have re-iterated the importance of behavioral interventions as well as the role of medications.
ADHD is common. A recent study found the world-wide pooled prevalence to be 3.4 %, with population surveys suggesting 5% occurrence among children.
Consequences of ADHD can be far ranging: disruptive behaviors, poor academic performance, absenteeism, lower graduation rates, lower rates of college enrollment, etc.
Diagnosis does not require additional testing, though it may be helpful.
Diagnostic and Statistical Manual of Mental Disorders criteria is as follows:
Persistent inattention and/or hyperactivity-impulsivity that impacts functioning
  1. Includes at least six or more inattentive and/or 6 or more hyperactive symptoms, lasting at least 6 months.
  2. Several of the symptoms were present prior to age 12.
  3. Several of the symptoms are present both at school and at home.
Treatment begins with behavioral interventions
1.Parent support
One example is Parent Management Training – an evidence supported approach to helping parents encourage positive behaviors and set limits, https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html
2.Classroom management techniques
Through a formal Individualized Educational Plan or other approaches that may include accommodations such as allowing a student timeouts, preferred seating, reminders etc.
Individual therapeutic interventions with the child
Organizational skills, study strategies, management of emotions and behaviors associated with school performance, etc.
Medication management can be effective
1.Typically for ages 6 and above, use of FDA approved medications for ADHD, in-combination with above behavioral interventions
Methylphenidate, Amphetamine, Guanfacine, clonidine and Atomoxetine
2. Dosing strategies and additional information can be found in Pediatric Psychopharmacology For Primary Care.
REFERENCES:
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.5th ed. Washington, DC: American Psychiatric Publishing; 2013
Groenman, A. P., Hornstra, R., Hoekstra, P. J., Steenhuis, L., Aghebati, A., Boyer, B. E., Buitelaar, J. K., Chronis-Tuscano, A., Daley, D., Dehkordian, P., Dvorsky, M., Franke, N., DuPaul, G. J., Gershy, N., Harvey, E., Hennig, T., Herbert, S., Langberg, J., Mautone, J. A., … van den Hoofdakker, B. J. (2022).
An Individual Participant Data Meta-analysis: Behavioral Treatments for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 61(2), 144–158. https://doi.org/10.1016/j.jaac.2021.02.024
Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: ameta-analysis of the worldwide prevalence of mental disorders in children and adoles-cents. J Child Psychol Psychiatry. 2015;56:345-365.https://doi.org/10.1111/jcpp.12381
Riddle, M. (2019) Pediatric Pharmacology For Primary Care. American Academy of Pediatrics
Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Ulrich Lehmann, C., Robert Lessin, H., Okechukwu, K., Pierce, K. L., Winner, J. D., Zurhellen, W., & Larner, R. (2019). Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. In Pediatrics (Vol. 144, Issue 4). http://publications.aap.org/pediatrics/article-pdf/144/4/e20192528/1078222/peds_20192528.pdf
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