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Screening, Referral and Treatment for Attention Deficit and Hyperactivity Disorder (ADHD) - Pediatric - Ambulatory

Screening, Referral and Treatment for Attention Deficit and Hyperactivity Disorder (ADHD) - Pediatric - Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Psychiatry


1


Screening, Referral and Treatment for
Attention Deficit and Hyperactivity
Disorder (ADHD) – Pediatric –
Ambulatory
Clinical Practice Guideline


Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ....................................................................................................................................... 3
SCOPE ................................................................................................................................................................ 4
METHODOLOGY ................................................................................................................................................. 4
INTRODUCTION.................................................................................................................................................. 5
RECOMMENDATIONS ......................................................................................................................................... 6
PRESENTATION AND SCREENING .......................................................................................................................... 7
CLINICAL EVALUATION .......................................................................................................................................... 7
EVALUATION OF SYMPTOMS .............................................................................................................................. 10
PROVIDE TREATMENT ......................................................................................................................................... 11
COMPLETE FOLLOW-UP CARE ............................................................................................................................. 13
UW HEALTH IMPLEMENTATION ........................................................................................................................ 15
REFERENCES ...................................................................................................................................................... 18
APPENDIX A. EVIDENCE GRADING SCHEME(S) ................................................................................................... 22
APPENDIX B. DSM-5 DIAGNOSTIC CRITERIA ....................................................................................................... 23
APPENDIX C. MEDICATION ALGORITHM ............................................................................................................ 25
APPENDIX D. MEDICATION TABLES .................................................................................................................... 26
APPENDIX E. ADHD HEDIS MEASURE ................................................................................................................. 31






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Contact for Content:
Name: Julie Gocey, MD ± Pediatrics
Phone Number: (608) 828-7602
Email Address: julie.gocey@uwmf.wisc.edu
Name: Timothy Chybowski, MD ± Pediatrics
Phone Number: (608) 287-2580
Email Address: timothy.chybowski@uwmf.wisc.edu
Contact for Changes:
Name: Janna Lind, MSN ± Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6695
Email Address: jlind@uwhealth.org
Coordinating Team Members:
Janet Lainhart, MD ± Psychiatry
Greg Rogers, PhD ± Psychology
Nicole Weathers, MD ± Family Medicine
Erri Hewitt, PhD ± Behavioral Health
Jessica Uftring, RN ± Clinical Staff Education
Kristine Moses, RN, BSN ± Clinical Nursing Supervisor
Denise Schmitt, RN, MS ± Clinical Nursing Supervisor
Paige Warren ± Information Services
Josh Vanderloo, PharmD ± Drug Policy Program
MaryAnn Steiner, PharmD ± UW Health Pharmacy Benefits Management Program
Sandy Jacobson, Director ± Ambulatory Operations
Jennifer Grice, PharmD, BCPS ± Center for Clinical Knowledge Management
5\OH\�2¶%ULHQ�± Center for Clinical Knowledge Management
Kim Hein-Beardsley, MS, LMFT ± Unity Liaison
Harvey Weinberg, PhD ± Gunderson Health Plan
Sarah Boyd, RN ± Physicians Plus Insurance Corporation
Alicia Plummer, MD ± Dean West Pediatrics
Jennifer Kuroda ± Swedish American
Lindsay Riesch, PhD ± Waisman Center
Shanna Vander Galien, MSW ± Waisman Center
Review Individuals/Bodies:
Tanya Lettman-Shue, MS, LMFT, CSAC, CSIT ± Journey Mental Health
Camilla Matthews, MD ± Wisconsin Sleep Center
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 10/27/16)
Release Date: October 2016 | Next Review Date: October 2018
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Executive Summary
Guideline Overview
This guideline is primarily based upon the 2007 American Academy of Child and Adolescent
Psychiatry and 2011 American Academy of Pediatrics (AAP) guidelines.

Key Revisions (2016 Periodic Review)
1. Added information on sleep disorders and Autism Spectrum Disorders.
2. Recommend use of the Vanderbilt rating scale.
3. Added recommendation for 4 and 5 year olds with ADHD and concerns for personal safety.
4. Modified recommendation for medication holidays (not universally recommended, consider
individual patient factors).
5. Added section on complimentary and alternative therapies.

Key Practice Recommendations
Practice Recommendations should be copied verbatim from the source document to accurately
depict the intention of the recommendations. Depending upon the guideline, include pertinent
recommendations only.
1. To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria have been met
(including documentation of impairment in more than 1 major setting); information should be
obtained primarily from reports from parents or guardians, teachers, and other school and
PHQWDO�KHDOWK�FOLQLFLDQV�LQYROYHG�LQ�WKH�FKLOG¶V�FDUH��7KH�SULPDU\�FDUH�FOLQLFLDQ�Vhould also
rule out any alternative cause.1 (AAP Quality of evidence B, strong recommendation)
2. ADHD is a clinical diagnosis made after consideration of other disorders which can also
cause hyperactivity or inattentive behaviors. The primary care clinician should assess for
other conditions that might coexist with ADHD, including emotional or behavioral (e.g.,
anxiety, depressive, oppositional defiant, and conduct disorders), developmental (e.g.,
learning and language disorders or other neurodevelopmental disorders), and physical (e.g.,
tics, sleep apnea, absence seizures) conditions.1 (AAP Quality of evidence B, strong
recommendation)
3. For both initial and ongoing evaluation of ADHD, the preferred rating scale is the NICHQ
Vanderbilt Assessment Scale (long form) for both parent/guardian and teacher informant in
patients age 4-5 years (UW Health Very low quality, weak/conditional recommendation), 6-12
years (UW Health Low quality evidence, strong recommendation), and 13-17 years.1,2 (UW Health
Very low quality evidence, weak/conditional recommendation)
4. Children (4-5 years): The first line of treatment should be evidence-based parent/guardian
and/or teacher-administered behavior therapy.1 (AAP Quality of evidence A, strong
recommendation) Providers may prescribe stimulant medication if the behavior interventions
do not provide significant improvement and there is moderate-to-severe continuing
disturbance in function.1 (AAP Quality of evidence B, recommendation) In severe cases involving
concerns for safety or personal harm to the patient or others, stimulant medication may be
used as first line therapy with referral to Developmental Pediatrician, Pediatric Psychology,
or Pediatric Psychiatry3-5 (UW Health Moderate quality evidence, weak/conditional
recommendation)
5. Children (6-11 years): Prescription of FDA-approved medications for ADHD1 (AAP Quality of
evidence A, strong recommendation) and/or evidence-based parent and/or teacher-
administered behavior therapy should be completed for treatment. It is preferred to prescribe
both medication and behavioral therapy.1 (AAP Quality of evidence B, strong recommendation)
6. Adolescents (12-18 years): FDA-approved medications for ADHD should be prescribed with
the patient assent.1 (AAP Quality of evidence A, strong recommendation) Behavioral therapy
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may be prescribed, as treatment using both methodologies is preferred.1 (AAP Quality of
evidence C, recommendation)

Companion Documents
1. Pediatric ADHD Algorithm
2. Pediatric ADHD Medication Algorithm
3. Pediatric Medication Tables
Scope
Disease/Condition(s): Attention deficit and hyperactivity disorder (ADHD)

Clinical Specialty: Family Medicine, Pediatrics, Neurology, Psychiatry, and Psychology

Intended Users: Primary Care Physicians, Advanced Practice Providers, Psychiatrists,
Psychologists, Pharmacists, Nurses

Objective(s): To provide evidence-based recommendations that support clinical decision
making during developmental surveillance, diagnosis, and treatment of pediatric patients with
ADHD

Target Population: Children (age 4-10 years) and adolescent (age 11-17 years) patients.
Consider referral for further evaluation to Behavioral Health or Neurology for children younger
than 4 years who present with behavior problems inconsistent with developmental level.

Interventions and Practices Considered:
ξ Behavioral therapy
ξ Medication
ξ Treatment of comorbid conditions

Major Outcomes Considered:
ξ Achievement of target behaviors at home and school
ξ Improved academic performance
ξ Improved peer and family relationships



Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

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Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: Starting in kindergarten, African American
children and some Latino children are less likely than Caucasian children to be diagnosed with
ADHD. This is despite a similar frequency of ADHD-related behaviors in the classroom. Non-
white children continue to be diagnosed with ADHD at lower rates through eighth grade.6-9 Of
those diagnosed with ADHD, African-American children and adolescents were less likely to
receive methylphenidate than Caucasian children.10-12

Introduction
ADHD is a condition which extends across developmental phases and may extend into
adulthood. Core symptoms include hyperactivity, impulsivity, and distractibility resulting in
academic, occupational, social, and personal underachievement. While the strongest risk factor
is genetic predisposition, the presentation and severity of the disorder results from complex
interactions among genetic, psychosocial, environmental, and biologic factors.13 ADHD is a
common behavioral diagnosis in primary care with substantial burden in terms of number of
visits, cost of medication, behavioral management and additional service costs (i.e. injury costs,
etc.).14,15 Diagnosis of ADHD requires evaluation of behavior across multiple settings,
consideration of alternative causes, and possible comorbidities. A multimodal management
plan, involving both the family, healthcare team, and school professionals, is essential. Early
recognition, diagnostic accuracy, and optimal management, including family and educational
support, contribute to improved short and long term functioning for both the child and his or her
family.1,16

This guideline is meant to address the care of children ages 4 ± 17 years. Consider referral for
further evaluation to Behavioral Health (Pediatric Psychiatry or Psychology), Developmental
Pediatrics, and/or Neurology for children younger than 4 years who present with significant
behavior problems that are DW\SLFDO�IRU�WKH�FKLOG¶V�developmental level. Patients aged 18 years
and older may be evaluated using the recommendations within UW Health ADHD ± Adult -
Ambulatory Clinical Practice Guideline.
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Recommendations
Suspect ADHD
Hyperactive, can’t sit still and/or
Lack of attention, poor concentration, daydreams, doesn’t listen and/or
Acts without thinking/impulsive and/or
Leading to functional impairment at home and school
Family and Child Assessment
1. History of present illness (HPI), including specific behaviors of concern, age of onset, duration,
parental expectations, general temperament, degree of functional impairment, settings and previous
interventions
2. Past medical history, including prenatal, childhood development, and substance abuse
3. Family history, especially learning disorders, alcohol and other drug issues (AODA), conduct disorders,
ADHD, sudden death and cardiac problems
4. Physical exam with particular attention to vision, hearing, sleep, genetics, and neurologic disorders
5. Consider lead screen, TSH, CBC/serum ferritin if history suggestive
6. Social history, including family organization, living arrangements, significant stressors
7. Educational history, including number of schools, need for special help, evaluations
Gather Information
1. Parents and other caregivers complete Vanderbilt rating scale
2. Teachers complete Vanderbilt rating scale
3. School evaluations (including IEP)
4. Report cards to document academic and social impairment and attendance patterns
5. Information from other clinicians (behavioral health, specialists, tutors, etc.)
Pediatric ADHD Algorithm (ages 4-17 years)
Consider Co-morbid and Confounding Disorders
1. Normal developmental variation or unrealistic parental or school expectations
2. Obsessive compulsive disorder (OCD)
3. Affective disorders (i.e., depression, anxiety)
4. Oppositional defiant/intermittent explosive/conduct disorder
5. Sequela of abuse/trauma
6. Developmental disorders, including Autism Spectrum disorders
7. Undiagnosed cognitive or learning disorder
8. Sleep disorders
9. Sensory processing disorders
10. Substance abuse
Determine Diagnosis
1. Meet DSM-5 criteria
Consider Referral
1. Neurological disorder
2. Extreme family or child dysfunction
3. Significant psychiatric disorders
4. Possibility of undiagnosed learning
disorder
Treatment
1. Family and patient education regarding diagnosis
2. Parenting strategies for behavior management
3. Educational planning and accommodations
4. Refer for family therapy or counseling and management training if needed
5. Medications
Follow-up
1. Prior to appointment, ask parents and teachers to complete follow-up Vanderbilt rating scales
2. Review parent and teacher rating scale results, target symptoms, home behavior, and school performance
3. Monitor for drug adverse effects (e.g., sleep, appetite), reinforce importance of drug adherence, and adjust drug therapy if needed
4. Reconsider comorbid and/or confounding disorders as needed
5. Monitor height, weight, pulse and blood pressure at each visit
6. Discuss parent concerns/questions and determine need for resources for
parent/guardian depression, ADHD, or other mental health concern
See Medication
Algorithm and Table(s)
ADHD- Pediatric – Ambulatory Guideline

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PRESENTATION AND SCREENING
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.1 (AAP Quality of evidence B, strong recommendation)

Parents/guardians (or anyone representing the patient such as a non-parent relative, other
caregiver, or school nurse) may request evaluation for ADHD because of their own concerns or
at the suggestion of a teacher, therapist, or other caregiver. The following behaviors are
consistent with ADHD if they are present and inconsistent with developmental level, and result
in functional impairment. A child with ADHD might:17
ξ daydream a lot
ξ forget or lose things a lot
ξ squirm or fidget
ξ talk too much, interrupt others
ξ make careless mistakes or take unnecessary risks
ξ have a hard time resisting temptation
ξ act without thinking
ξ have trouble taking turns
ξ have difficulty getting along with others
ξ avoid task that require focus

See Appendix B for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
criteria for ADHD.
CLINICAL EVALUATION
To make a diagnosis of ADHD, the primary care clinician should determine that Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition criteria have been met (including
documentation of impairment in more than 1 major setting) (see Appendix B); information
should be obtained primarily from reports from parents or guardians, teachers, and other school
DQG�PHQWDO�KHDOWK�FOLQLFLDQV�LQYROYHG�LQ�WKH�FKLOG¶V�FDUH��7KH�SULPDU\�FDUH�FOLQLFLDQ�VKRXOG�DOVR�
rule out any alternative cause.1 (AAP Quality of evidence B, strong recommendation)

Initial evaluations can usually be done in the primary care office, reserving referrals to Pediatric
Psychiatry, Developmental Pediatrics, or Behavioral Pediatrics for those situations where the
diagnosis is uncertain or family situation is complicated. Evaluation should consist of clinical
interviews with the parent/guardian DQG�SDWLHQW��REWDLQLQJ�LQIRUPDWLRQ�DERXW�WKH�SDWLHQW¶V�VFKRRO�
or daycare functioning, evaluation for comRUELG�SV\FKLDWULF�GLVRUGHUV��DQG�UHYLHZ�RI�WKH�SDWLHQW¶V�
medical, social, and family histories. Data collection prior to a clinic visit is typically helpful, and
more than one visit may be needed to perform the entire clinical assessment (e.g.,
parents/guardians may come without their children).

History of Present Illness
ξ The history of present illness should include a thorough description of the behaviors of
concern, including age of onset, duration, and degree of functional impairment.16 The
location and circumstances in which the behaviors occur should be assessed, as well as
what interventions have been tried.
ξ Behaviors should be considered within the context of normal developmental variation,
individual temperament, and parental/guardian expectations.

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Past Medical History
ξ Past medical history should include any prenatal, birth, or childhood medical insults (e.g.,
seizures, head trauma, stroke, encephalitis, maternal smoking, prenatal exposures, chronic
ear infections, premature or difficult birth, etc.) which could contribute to the behavioral
concerns.
ξ Information from other clinicians including behavioral health providers, medical specialists,
etc. should be reviewed.

Family history
ξ Children with ADHD often have a positive family history for ADHD and associated concerns,
such as learning problems, mood or anxiety disorders, or conduct disorders.18-20
ξ Substance abuse can represent a consequence of inadequate treatment or undiagnosed
ADHD in adults.21,22 Having family members or care givers with alcohol and other drug
issues is a risk for diversion of medication. Consider evaluation for drug-seeking behavior
with multiple pharmacies or prescribing providers using the Wisconsin Prescription Drug
Monitoring Program.
ξ A family history of sudden death or early cardiac problems should prompt review prior to
using stimulant medications. Electrocardiography (ECG) may be considered prior to initiation
of stimulant therapy if indicated by risk factors determined by family or individual history or
during review of systems.23-27 (UW Health Moderate quality evidence, weak/conditional
recommendation)

Social History
ξ It is important to assess current living arrangement and parenting patterns. Chaotic home
situations can produce behavior problems similar to ADHD or make treatment of a child with
ADHD more difficult.
ξ Significant stressors, including family disruption, divorce, frequent moves, significant losses,
history of abuse or neglect, and parental mental health should be assessed.28-30
ξ Lifestyle factors, such as sleep patterns, amount of screen time, exercise habits, and
structured home life/schedules should also be assessed.31-34

History of Educational Issues
ξ Clinicians should inquire whether behaviors occur in specific classes or at certain times of
the day, in consideration of the likelihood of a learning disorder.
ξ It is helpful to review results from any school-based evaluations and to consider any special
help or classroom accommodations that have been provided.
ξ Report cards can be used to document performance as well as behavioral concerns.
ξ Attendance problems should be considered as they can indicate school avoidance due to
anxiety, physical problems, or chaotic parenting.

Physical Exam
A physical exam, including review of systems, should be performed as part of the initial
evaluation for ADHD if the patient has not had a Well Child Visit within the previous year. (UW
Health Very low quality evidence, Strong recommendation)

Vision or hearing deficits, sleep inadequacy, migraines, pica, or lead poisoning can all contribute
to difficulty in function. Vision and hearing screening or lab work (such as lead screening,
complete blood count (CBC), ferritin, TSH) may be considered if indicated. (UW Health Moderate
quality evidence, weak/conditional recommendation) However, iI�D�SDWLHQW¶V�PHGLFDO�KLVWRU\�LV�
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unremarkable, laboratory testing or neurological testing is not indicated.16 (UW Health Very low
quality evidence, weak/conditional recommendation)

Comorbid and/or Confounding Disorders
ADHD is a clinical diagnosis made after consideration of other disorders which can also cause
hyperactivity or inattentive behaviors. The primary care clinician should assess for other
conditions that might coexist with ADHD, including emotional or behavioral (e.g., anxiety,
depressive, oppositional defiant, and conduct disorders), developmental (e.g., learning and
language disorders or other neurodevelopmental disorders), and physical (e.g., tics, sleep
apnea, absence seizures) conditions.1 (AAP Quality of evidence B, strong recommendation)

Some other comorbid and/or confounding disorders that can cause symptoms of hyperactivity or
inattentiveness include the following and are described in greater detail below:
ξ Normal developmental variation or unrealistic parental/guardian or school expectations
ξ Obsessive compulsive disorder (OCD)
ξ Affective disorders (e.g., depression, anxiety)
ξ Oppositional defiant/intermittent explosive/ conduct disorder
ξ Sequela of abuse/trauma
ξ Developmental disorders, including Autism Spectrum Disorders
ξ Undiagnosed cognitive or learning disorder
ξ Sleep disorders
ξ Sensory processing disorders
ξ Substance abuse

Psychiatric evaluation is indicated for concern regarding any significant psychiatric or mood
disorder. For patients undergoing evaluation for other psychologic dysfunctions in addition to
ADHD, it may be appropriate to use a different rating scale with broader scope of assessment in
lieu of or in addition to the Vanderbilt. (UW Health Low quality evidence, weak/conditional
recommendation) Families with histories of or with ongoing abuse, high stress levels or
dysfunctional parenting may benefit from referral to Behavioral Health. (UW Health Low quality
evidence, weak/conditional recommendation)

ADHD symptoms can mask core symptoms of Autism Spectrum Disorders (ASD). Examples of
overlapping symptoms include becoming easily distracted, often not seeming to listen when
spoken to, avoidance/reluctance to do certain activities (behavioral rigidity), having
conversational deficits like interrupting and talking excessively, having trouble waiting his/her
turn, often fidgeting (may not be obviously atypical mannerisms), or running and climbing when
inappropriate. It is recommended that a team of experts evaluate a child with co-occurring
symptoms of ADHD and ASD. A referral to a Psychologist, Developmental Pediatrician, or an
Autism treatment center for evaluation is appropriate.35 (UW Health Low quality evidence,
weak/conditional recommendation)

A referral to a center which specializes in interdisciplinary evaluation (e.g., the Waisman Center
in Madison) is appropriate to differentiate complicated cases of behavioral symptoms related to
a range of neurodevelopmental disorders and suspected ASD. The Waisman Resource Center
serves to provide information about community resources to patients and families. (800-532-
3321 or wrc@waisman.wisc.edu )

Learning disorders are frequently a comorbid or alternative diagnosis. Neuropsychological and
psychological tests should be performed by a specialist LI�WKH�SDWLHQW¶V�KLVWRU\�VXJJHVWV�ORZ�
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JHQHUDO�FRJQLWLYH�DELOLW\�RU�ORZ�DFKLHYHPHQW�LQ�ODQJXDJH�RU�PDWKHPDWLFV�UHODWLYH�WR�WKH�SDWLHQW¶V�
intellectual ability.16 Referral to the school for further evaluation may also be appropriate,
especially if the behaviors are limited to one area of academic functioning, such as math or
reading, or there is concern about comprehension. (UW Health Very low quality evidence,
weak/conditional recommendation) This testing may not be covered by insurance. Patient
Resources may be able to provide information on specific testing agencies, including agencies
that provide training opportunities to graduate students and provide testing at a reduced rate.
Sleep problems are common in children with ADHD. The causes are likely multifactorial and
may include adverse effects of medications used to treat ADHD (See the Medication Treatment
Algorithm), factors intrinsic to ADHD, or comorbid conditions such as oppositional disorder or
mood disorders.36,37 In some cases, sleep disturbances may lead to ADHD-like symptoms.38
Referral for a sleep consultation is recommended for any child with nightly snoring, frequent
sleepwalking or night terrors, significant difficulty falling asleep or staying asleep, restless leg
symptoms, or daytime sleepiness in addition to symptoms of hyperactivity and inattention.39,40
(UW Health Moderate quality evidence, weak/conditional recommendation)
In the subset of patients who have symptoms of ADHD in addition to symptoms of a sensory
processing disorder, a referral to Pediatric Occupational Therapy may be considered.1,41 (UW
Health Very low quality evidence, weak/conditional recommendation)
Substance abuse can result in similar symptoms to ADHD or can represent a consequence of
inadequate treatment. For assessment of tobacco or alcohol use, reference the UW Health
Tobacco ± Pediatric/Adult ± Inpatient/Ambulatory Guideline or UW Health Alcohol ±
Pediatric/Adult ± Ambulatory Guideline. Consider evaluation for drug-seeking behavior with
multiple pharmacies or prescribing providers using the Wisconsin Prescription Drug Monitoring
Program.
EVALUATION OF SYMPTOMS
There are many rating scales based on the DSM-5 criteria that can be used for evaluation of
ADHD symptoms. The use of ADHD rating scales for diagnosis and follow up purposes is
historically low.42 Barriers to rating scale completion, including both clinic and patient factors
such as scale length or evaluator familiarity, may contribute to low usage of rating scales. The
ideal rating scale is validated, will reduce barriers to completion, includes items that evaluate for
common comorbid conditions (e.g., oppositional defiant disorder, anxiety), and is easy to use
and document in the electronic health record. Use of a consistent tool across settings and over
time is preferred for tracking changes in patient symptoms.
For both initial and ongoing evaluation of ADHD, the preferred rating scale is the NICHQ
Vanderbilt Assessment Scale (long form) for both parent/guardian and teacher informant in
patients age 4-5 years (UW Health Very low quality, weak/conditional recommendation), 6-12 years
(UW Health Low quality evidence, strong recommendation), and 13-17 years.1,2 (UW Health Very low
quality evidence, weak/conditional recommendation) While validation studies have been performed
on individuals between the ages of 6 and 12 only, these studies were only for the comparison of
normative data. The tool has been widely used to collect information required for a DSM-5
diagnosis in children and adolescents within the published medical literature.43,44
If a non-UW Health provider (including a school psychologist) initiated the ADHD evaluation
using a rating scale other than the Vanderbilt, the other rating scale (e.g., Connors, SNAP) can
still be used in the diagnosis of ADHD. However, it is recommended to transition to the
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Vanderbilt rating scale for ongoing follow up per above recommendations. (UW Health Low quality
evidence, weak/conditional recommendation)

When using the NICHQ Vanderbilt Assessment Scale, the teacher informant is ideally a current
teacher who has significant contact with the child. If the evaluation is taking place over the
summer or at tKH�EHJLQQLQJ�RI�WKH�VFKRRO�\HDU��WKH�SULRU�\HDU¶V�WHDFKHU�PD\�SURYLGH�WKH�PRVW�
valid ratings. Report cards, IEP evaluations, teacher notes, assessments from school
psychologists, and other documentation are valuable data and should also be used in the
evaluation of ADHD when available.

Obtaining completed rating scales from high school teachers is notoriously difficult. Although
use of both a parent/guardian and teacher informant rating scale is preferred, use of the ADHD
Self Assessment Scale may be considered in carefully selected older adolescents in lieu of a
teacher informant; a parent/guardian informant is still considered essential.45,46 (UW Health Very
low quality evidence, weak/conditional recommendation)
PROVIDE TREATMENT
Treatment consists of a variety of approaches including family and parenting support,
educational accommodations, behavioral therapy, and medication.

Treatment Recommendations by Age
Children (4-5 years): The first line of treatment should be evidence-based parent/guardian
and/or teacher-administered behavior therapy.1 (AAP Quality of evidence A, strong recommendation)
Providers may prescribe stimulant medication if the behavior interventions do not provide
significant improvement and there is moderate-to-severe continuing disturbance in function.1
(AAP Quality of evidence B, recommendation) In severe cases involving concerns for safety or
personal harm to the patient or others, stimulant medication may be used as first line therapy
with referral to Developmental Pediatrician, Pediatric Psychology, or Pediatric Psychiatry3-5 (UW
Health Moderate quality evidence, weak/conditional recommendation)

Children (6-11 years): Prescription of FDA-approved medications for ADHD1 (AAP Quality of
evidence A, strong recommendation) and/or evidence-based parent and/or teacher-administered
behavior therapy should be completed for treatment. It is preferred to prescribe both medication
and behavioral therapy.1 (AAP Quality of evidence B, strong recommendation)

Adolescents (12-18 years): FDA-approved medications for ADHD should be prescribed with
patient assent.1 (AAP Quality of evidence A, strong recommendation) Behavioral therapy may be
prescribed, as treatment using both methodologies is preferred.1 (AAP Quality of evidence C,
recommendation)

Behavioral Therapy
Behavioral therapy includes a broad set of psychosocial interventions, which can occur via
family counseling, parent support groups, self-education, and/or clinician visits. Behavioral
therapy typically includes training parents LQ�WHFKQLTXHV�LQWHQGHG�WR�VKDSH�WKH�FKLOG¶V�EHKDYLRU�
DQG�WR�LPSURYH�WKH�FKLOG¶V�DELOLW\�WR�UHJXODWH�his or her own behavior. Examples may include
emotion coaching for preschoolers, positive discipline techniques, social skills training, and
developing routines (organizational training). Behavioral therapy should be evidence-based and
DSSURSULDWH�WR�WKH�SDWLHQW¶V�DJH��GHYHORSPHQWDO�OHYHO��DQG�FRPRUELG�FRQGLWLRQV. Inquiring about
the aforementioned interventions to parents during primary care follow-up visits stresses their
importance and emphasizes parental roles in the complete treatment plan.47-52

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Students with disabilities, including those with ADHD, have legal protections that guarantee a
free and appropriate public education. Special services or educational accommodations are not
needed by all students with ADHD; however, it is important for all parents and guardians to
develop a constructive ZRUNLQJ�UHODWLRQVKLS�ZLWK�WKHLU�FKLOG¶V�WHDFKHUs and school. All parents
should be informed of the possibilities for obtaining a school-based evaluation to determine
eligibility for services (Section 504 of the Rehabilitation Act of 1974; Individuals with Disabilities
Education Act, 2004). In Wisconsin, if a public school district, administrator, or school
psychologist receives a written request for an evaluation they are legally required to meet with
the parents/guardians to see if an evaluation is needed. (See the Wisconsin Department of
(GXFDWLRQ¶V�$FFRPPRGDWLRQV�*XLGH) If a student is eligible for services through their school,
parents and guardians should expect to work with the school to develop and monitor an
HGXFDWLRQDO�SODQ�ZKLFK�PD[LPL]HV�WKH�FKLOG¶V�DFDGHPLF�IXQFWLRQLQJ�DQG�DFKLHYHPHQW��
Coordination with health care providers is an integral part of successful educational plans.
Additional resources and information may be obtained by contacting the school psychologist or
nurse.

Medication Therapy
Medication therapy is often a very effective tool in treating children with ADHD.53,54 Evidence
also suggests that medication therapy may ameliorate the structural differences observable in
the brains of patients with ADHD.55-57

It can take several attempts to find the most efficacious medication with the least side effects.
The medication treatment algorithm (Appendix C) reviews initial treatment choices and
management of common side effects. The medication chart (Appendix D) includes product
names, usual duration of action, available strengths, usual dosing, and contraindications/
precautions.

Medication success is based on reduction of target symptoms without problematic side-effects.
When medication therapy is effective, the treatment effect does not persist following
discontinuation. ³0HGLFDWLRQ�KROLGD\V´��GLVFRQWLQXDWLRQ�RI�PHGLFDWLRQ�XVH�GXULQJ�ZHHNHQGV�DQG�
summer break) are not universally recommended. The decision to continue or discontinue
ADHD medication during non-school days should be based on individual patient needs.58,59 (UW
Health GRADE Low quality evidence, weak/conditional recommendation)

Consider the following when forming and evaluating the medication plan (UW Health Very low
quality evidence, weak/conditional recommendation):
ξ Perform a baseline assessment before a medication is prescribed of common ADHD
medication adverse effects.
ξ Medication should be periodically re-evaluated in order to assess the recurrence of
symptoms with regard to attention and hyperactivity. When evaluating effectiveness of
medication, also consider other components of the treatment plan.
o Assess for adherence to the medication regimen. Missed doses are common both at
home and school.
o Determine if behavior therapy is being implemented.
o Determine if more educational support is needed.
ξ In situations where there is a significant risk of substance abuse or diversion by the patient
or their family members, non-stimulant preparations or slow-release stimulants are
preferred. When crushed, they more closely resemble immediate-release preparations in
terms of onset and effect.
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ξ Consider insurance coverage and costs of therapy when prescribing medication. Medication
costs can be a significant barrier to treatment for some families. Consider use of generic
medications and/or a referral to Patient Resources.
ξ Medications must be prescribed in accordance with Wisconsin Chapter 961 for controlled
substances:
o Prescription must be written for legitimate medical indication.
o Sign/date prescription on date of issue with:
 Patient full name/address.
 Drug name, strength, dosage form, quantity, directions for use.
o Up to 3 monthly prescriptions may be given to patients.
 The date of issue (date of prescription is written) must be on all three
prescriptions.
 7KH�SUHVFULEHU�ZULWHV�³ILOO�RQ�RU�DIWHU�;;�;;�;;;;´�IRU�WZR�SUHVFULSWLRQV�WR�EH�
filled at a later date.
 A prescription for a CII controlled substance cannot be dispensed more than 60
days after the date of issue on the prescription order.

Most children will respond to one or more of the stimulant medications; therefore, consider
referral to Psychiatry or a provider-to-provider consultation for children who do not respond after
several medication trials or who experience severe side effects. (UW Health GRADE Very low
quality evidence, weak/conditional recommendation)

Complimentary and Alternative Therapies (CAT)
Many families and patients express interest in using complimentary and alternative therapies to
treat ADHD. For some, it is because medication and/or behavioral therapies have been
ineffective, while others have concerns about the safety of long-term medication use. Behavioral
therapies may also be difficult to access for some families. Examples of CAT modalities used to
treat ADHD include restricted diets, nutritional supplements, and mind-body therapies such as
meditation, massage, acupuncture, neurofeedback, and working memory training.

Robust evidence to support the effectiveness of CAT therapies is lacking. Some studies show
modest benefit, however many of these studies are not methodologically strong. Due to the
lack of consistent supporting empirical evidence, CAT modalities are not recommended. (UW
Health Low quality evidence, weak/conditional recommendation) Discussion of CAT modalities with
families should include possible harms (e.g., restricted diet), burden on patients and families
(e.g., financial risk), and establishing patient and family values and interests. Patients and their
families should be encouraged to follow basic healthy lifestyle factors (e.g., structured sleep
schedule, exercise, limited screen time, nutritious diet) which are supported by emerging
literature.31-34 (UW Health GRADE Low quality evidence, weak/conditional recommendation)

COMPLETE FOLLOW-UP CARE
The primary care clinician should recognize ADHD as a chronic condition and, therefore,
consider children and adolescents with ADHD as children and youth with special health care
needs. Management of children and youth with special health care needs should follow the
principles of the chronic care model and the medical home.1 (AAP Quality of evidence B/strong
recommendation).

Based on UW Health consensus for chronic care management, patients with a new ADHD
diagnosis and a newly prescribed ADHD medication should be seen by a provider (MD, PA, or
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14

NP) in 2-3 weeks, and have two additional follow up appointments within the next 9 months.
(UW Health Very low quality evidence, weak/conditional recommendation) Follow-up within this
timeframe is a required Healthcare Effectiveness Data and Information Set (HEDIS) measure.
For more information, see Appendix E.

At each follow-up visit clinicians should complete the following (UW Health Low quality evidence,
weak/conditional recommendation):
ξ Ask parents/guardians and teacher to complete Vanderbilt rating scales and review results.
ξ Review target symptoms and home behavior.
ξ Review school performance including success of educational plan.
ξ Monitor for adverse effects to medications, if applicable, including effects on appetite and
sleeping patterns.
ξ Adjust medication therapy as needed.
ξ Reinforce the importance of medication adherence. Medication holidays are NOT universally
recommended but may be appropriate based on individual patient needs.
ξ Reconsider comorbid and/or confounding disorders, particularly when treatment goals are
not achieved.
ξ Periodic physical assessment including height, weight, pulse, and blood pressure.27,60,61
ξ Discuss parent/guardian concerns and questions. Review success of parenting strategies
and educational needs.
ξ Remind parents/guardians that caring for a child with ADHD can be challenging. Determine
if a referral to Patient Resources or elsewhere may be needed for the parent/guardian to
seek evaluation or treatment for possible depression, adult ADHD, or another mental health
concern.

Contrary to general recommendations for Well Child Visits in the Preventive Health Care
Guideline, all patients with ADHD should have annual well child checks, including patients who
see a psychiatrist or psychologist for ADHD management. (UW Health Very low quality evidence,
strong recommendation)





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15

UW Health Implementation
Potential Benefits: Appropriate assessment and treatment of children and adolescents with
attention-deficit/hyperactivity disorder

Potential Harms: Drug toxicity

Patient Resources
1. Health Facts For You #7902 What is ADHD?
2. Health Facts For You #7903 ADHD Care Guidelines
3. Health Facts For You #3202 ADHD New Diagnosis Packet
4. Healthwise: ADHD (Attention Deficit Hyperactivity Disorder): Pediatric
5. Kids Health: What is ADHD? (Parents)
6. Kids Health: ADHD Special Needs Factsheet (Parents)
7. Kids Health: Could ADHD Be Hereditary? (Parents)
8. Kids Health: Does Ritalin Have Side Effects? (Parents)
9. Kids Health: ADHD Medicines (Kids)
10. Kids Health: Word! ADHD (Kids)
11. Kids Health: What is Hyperactivity? (Kids)
12. Kids Health: ADHD Medicines (Teens)
13. Kids Health: ADHD: Tips to Try (Teens)
14. Kids Health: ADHD (Teens)
15. Kids Health: Is My ADHD Medication Affecting My Sleep? (Teens)
16. Health Information: ADHD (Attention Deficit/Hyperactivity Disorder)
17. Health Information: ADHD and Hyperactivity
18. Health Information: ADHD Medicines: Suicide Warning for Strattera
19. Health Information: ADHD Myths and Facts
20. Health Information: ADHD: Helping Your Child Get the Most From School
21. Health Information: ADHD: Helping Your Child Get Things Done
22. Health Information: Impulsivity and Inattention
23. Health Information: Other Conditions With Similar Symptoms
24. Health Information: Should My Child Take Medicine for ADHD?
25. Health Information: Social Skills Training
26. Health Information: Taking Care for Yourself When Your Child Has ADHD
27. Health Information: ADHD: Tests for Other Disorders
28. Lexicomp: Attention Deficit Hyperactivity Disorder (ADHD)
29. Lexicomp: Attention Deficit Hyperactivity Disorder (ADHD) Discharge Instructions
30. Lexicomp: Medicines for Attention Deficit Hyperactivity Disorder (ADHD)
31. Lexicomp: Methylphenidate (Pediatric)
32. Lexicomp: Dexmethylphenidate (Pediatric)
33. Lexicomp: Dextroamphetamine (Pediatric)
34. Lexicomp: Dextroamphetamine and Amphetamine (Pediatric)
35. Lexicomp: Lisdexamfetamine (Pediatric)
36. Lexicomp: Bupropion (Pediatric)
37. Lexicomp: Atomoxetine (Pediatric)
38. Lexicomp: Clonidine (Pediatric)
39. Lexicomp: Guanfacine (Pediatric)




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Guideline Metrics
Meaningful Use:
1. Percentage of children who had one follow-up visit with a practitioner with prescribing
authority during the 30-day initiation phase.
2. Percentage of children, who remained on ADHD medication for at least 210 days and who,
in addition to the visit in the Initiation Phase, had at least 2 additional follow-up visits within
270 days after the Initiation Phase ended.

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Order Sets & Smart Sets
ADD/ADHD [73]

Reporting Workbench Reports
UWOP Pediatric Patients with ADHD [7643988]
My Patients with ADHD [7865026]

Smart Texts
1. ADHD Initial Eval [16832]
2. ADHD Follow Up And Medication Management Progress Note ± Pediatric [74652]
3. ADHD Refill [16818]
4. ADHD Recheck [16831]
5. ADHD Brief Care Plan [74661]
6. PI ADHD Neuropsychology Testing Options [74727]
7. MCHC ADD/ADHD Followup [10421]
8. MCHC ADD PATIENT Instructions English [10429]
9. Pre-Visit Peds Concern Screen ADHD [35022]
10. ADHD Phone Follow Up
11. ADHD Brief Care Plan - Problem List [74661]
12. ADHD Phone Intake [77192]
Smart Phrases ± System
1. ROOMINGFUADD [369945]
2. ADHDINITALEVAL [236179]
3. ADHDMEDCHECK [485903]
4. ADHDRECHECK [253302]
5. ADHDREFILL [235327]
6. VANDERBILT [355045]
7. FLOWADULTADHDSELFREPORTINGSCALE [410674]


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Smart Links
1. UWOP SBAR ADHD Phone Follow Up [100987]
2. UWOP SBAR ADHD Phone Intake [100986]
3. UW OP ADHD Medication Initiation Date [100933]
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
iQWHQGHG�WR�UHSODFH�D�FOLQLFLDQ¶V�MXGJPHQW�RU�WR�HVWDEOLVK�D�SURWRFRO�IRU�DOO�SDWLHQWV��,W�LV�
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

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18

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21

56. Spencer TJ, Brown A, Seidman LJ, et al. Effect of psychostimulants on brain structure
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Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.


Figure 2. American Academy of Pediatrics Grading Scheme (2011)


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23

Appendix B. DSM-5 Diagnostic Criteria

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development, as characterized by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months
to a degree that is inconsistent with developmental level and that negatively impacts
directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance,
hostility, or failure to understand tasks or instructions. For older adolescents and
adults (age 17 and older), at least five symptoms are required.
a. Often fails to give close attention to details or makes careless mistakes in
schoolwork, at work, or during other activities (e.g., overlooks or misses details,
work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has
difficulty remaining focused during lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems
elsewhere, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and
is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing
sequential tasks; difficulty keeping materials and belongings in order; messy,
disorganized work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained
mental effort (e.g., schoolwork or homework; for older adolescents and adults,
preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials,
pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults,
may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older
adolescents and adults, returning calls, paying bills, keeping appointments).

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have
persisted for at least 6 months to a degree that is inconsistent with developmental
level and that negatively impacts directly on social and academic/occupational
activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance,
hostility, or a failure to understand tasks or instructions. For older adolescents and
adults (age 17 and older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or
her place in the classroom, in the office or other workplace, or in other situations that
require remaining in place).
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c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents
or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. ,V�RIWHQ�³RQ�WKH�JR�´�DFWLQJ�DV�LI�³GULYHQ�E\�D�PRWRU´��H�J���LV�XQDEOH�WR�EH�RU�
uncomfortable being still for extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes
SHRSOH¶V�VHQWHQFHV��FDQQRW�ZDLW�IRU�WXUQ�LQ�FRQYHUVDWLRQ��
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities;
PD\�VWDUW�XVLQJ�RWKHU�SHRSOH¶V�WKLQJV�ZLWKRXW�DVNLQJ�RU�UHFHLYLQJ�SHUPLVVLRQ��IRU�
adolescents and adults, may intrude into or take over what others are doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12
years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more
settings (e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of,
social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or
another psychotic disorder and are not better explained by another mental disorder
(e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder,
substance intoxication or withdrawal).


DSM-5 Diagnosis
Specify whether:
Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-
impulsivity) are met for the past 6 months.
Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2
(hyperactivity-impulsivity) is not met for the past 6 months.
Predominately hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is
met and Criterion A1 (inattention) is not met for the past 6 months.

Specify if:
In partial remission: When full criteria were previously met, fewer than the full criteria have been
met for the past 6 months, and the symptoms still result in impairment in social, academic, or
occupational functioning.

Specify current severity:
Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, and
symptoms result in no more than minor impairments in social or occupational functioning.
Moderate��6\PSWRPV�RU�IXQFWLRQDO�LPSDLUPHQW�EHWZHHQ�³PLOG´�DQG�³VHYHUH´�DUH�SUHVHQW�
Severe: Many symptoms in excess of those required to make the diagnosis, or several symptoms
that are particularly severe, are present, or the symptoms result in marked impairment in social or
occupational functioning.


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25

Appendix C
Target Behaviors at Home and School Identified
Stimulant Medication
No particular advantage to either Methylphenidate or Amphetamine. Start with low dose. The use of a long-acting stimulant will promote continuous,
stable therapy throughout the day. There is no need to start treatment with a short-acting agent first, prior to switching to a long-acting agent. Referral is
appropriate for child with unusual responses or whenever a clinician has concerns about further treatment. See medication chart for precautions/
contraindications.
Improved target
behaviors and function?
Side effects present?
* Appetite loss – give with meal;
snack late in the evening
* Insomnia – behavior problems
vs. side effects vs. anxiety; lower
dose; give last dose of day earlier
* Sadness – reevaluate diagnosis;
reduce dose; switch to long acting
(peak of short acting can cause
sadness)
* Worsening behavior (rebound) –
switch to long acting; overlap
short and long acting; add other
medication (bupropion)
* Irritability – if soon after dose,
could be related to peak - switch
to long acting; if late could be
rebound – reduce dose
Switch to other stimulant class, if
above is not successful, increasing
dose until target behaviors and
function improved or side effects
redevelop
Reconsider diagnosis of ADHD and assess for missed
comorbid conditions. Consider psychiatry referral.
Periodic follow-up to monitor:
* Target behavior outcomes
* Academic progress
* Adverse effects of medication

Consider long acting dose and
medication equivalent for
maintenance treatment
Satisfactory response to
treatment plan?
Continue systematic follow-up at least
twice yearly. Monitor height, weight,
blood pressure and sleep.
Pediatric ADHD Medication Algorithm
Last revised/reviewed: 09/2016
ADHD ± Pediatric ± Ambulatory Guideline
Contact CCKM for revisions.
Increase dose until target behaviors
and function improved or side
effects develop
Switch to non-stimulant alternative
(atomoxetine, bupropion, tricyclic,
clonidine, or guanfacine)
Yes
Yes
No
Side effects present?
No
Yes
Improved target
behaviors and function?
No
No
Yes
Improved target
behaviors and function?
No
Yes
Patient on
stimulant?
No
No
Yes
Dose
maximized?
Yes
No
Yes

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26

Appendix D
Medications for Treatment of Attention-Deficit/Hyperactivity Disorder (Pediatric)
GENERAL CONSIDERATIONS FOR STIMULANTS
ξ Despite lack of FDA approval for age <6 years, safety and effectiveness have
been demonstrated and off label use may be appropriate in selected children
under 6.1,3-5 Consultation with Pediatric Psychiatry is encouraged.
ξ Initiate therapy with a long acting stimulant to promote continuous, stable
therapy throughout the day.
ξ Consider duration of formulation with regard to interference with sleep
ξ Because of different stimulant combinations (methylphenidate or
amphetamine) and kinetic profiles, do not substitute on a mg-per-mg basis.
ξ Nonabsorbable tablet shell may be seen in stool (Concerta)
ξ Monitor patient weight and vital signs
ξ Swallow tablets whole with liquids. If patient is unable to swallow,
consider alternative formulations or capsules may be opened and
sprinkled on food. Beads inside capsules should NOT be chewed.
ξ Consider cardiac risk factors prior to initiating therapy (e.g., cardiac
hypertrophy, family history of ventricular arrhythmia, murmur,
palpitations, near syncope)
ξ Use cautiously if history of tics, seizures, anorexia nervosa, anxiety,
or history of substance misuse or diversion
ξ Most common side effects include appetite suppression, weight loss,
insomnia or headache
Methylphenidate Products
Product Names Strengths Available
Duration
of Action
Usual Dosing
Pediatric Titration Dose
(titrate every 7 days, unless
otherwise indicated)
Maximum Daily Dose
Short acting
methylphenidate tab^* (Ritalin) 5,10, 20 mg tabs ”���KRXUV� 5-20 mg given 2-3 times daily Titrate by 5-10 mg every 7-14 days
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate tab ^* (Methylin)
(equivalent to Ritalin)
2.5, 5, 10, 20 mg tabs
5 mg/5mL, 10mg/5mL
solution
2.5, 5, 10 mg chew tabs
”���KRXUV
5±20 mg given 2-3 times daily
Titrate by 5-10 mg every 7-14 days
FDA: 60 mg
Off label: 100 mg if over
50 kg
Intermediate
acting 4-6
hours
methylphenidate SR tab^*
(Ritalin SR) 20 mg tabs 4 ± 6 hours
20±60 mg (divided in 1-2 doses/day)
(20-40 mg in morning, 20 mg in
early afternoon)
Titrate by 20 mg/day
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate^* (Methylin ER)
(equivalent to Ritalin SR) 10,20 mg tabs 4 ± 6 hours 10-60 mg daily
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate ER tab^*
(Metadate ER) 20 mg tabs 4 ± 6 hours
20-60 mg daily (divided in 1-2
doses/day)
FDA: 60 mg
Off label: 100 mg if over
50 kg
dexmethylphenidate^* (Focalin) tab 2.5, 5, 10 mg tabs 4 ± 6 hours 2.5±10 mg given twice daily at least
twice daily at 4 hours apart
FDA: 20 mg
Off label: 50 mg
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27

Intermediate
acting 6-8
hours
methylphenidate* ^ (Metadate CD)
cap (bimodal release with 30% rapid
onset and 70% delayed release)
10, 20, 30, 40, 50, 60
mg caps 6 ± 8 hours
10-60 mg daily
Titration 10-20 mg
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate ER*^§ (Ritalin LA)
cap (bimodal release with 50% rapid
onset and 50% delayed release)
10, 20, 30, 40 mg caps 6 ± 8 hours 20-60 mg daily
FDA: 60 mg
Off label: 100 mg if over
50 kg
methylphenidate § (Aptensio XR)
cap (bimodal release with 40% rapid
onset and 60% delayed release)
10, 15, 20, 30, 40, 50,
60 mg caps 8 hours
10 mg daily
Titrate every week FDA: 60 mg
Long acting
dexmethylphenidate*^§ (Focalin XR)
cap (bimodal release with 50% rapid
onset and 50% delayed release)
5, 10, 15, 20, 25, 30,
35, 40 mg caps

(25 & 35 mg are not
available generic)
10 - 12
hours
5-20 mg
once daily
5±40 mg daily
(titrate by 5 mg for children)
FDA: 30 mg for children,
40 mg adults
Off label: 50 mg
methylphenidate ^ (Daytrana) patch
apply to hip for 9 hours
10, 15, 20, 30 mg patch
12 hours
(with 2 -3
hour delay)
10-30 mg patch daily
Titrate by next highest strength patch FDA: 30 mg
methylphenidate *^§ (Concerta) tabs
(bimodal release with 22% rapid
onset and 78% delayed release)
18, 27, 36, 54 mg tabs 10 hours 18-54 mg once daily
(titrate by 18 mg)
FDA: 54 mg for children,
72 mg for adolescents
and adults
Off label: 72 mg
�FKLOGUHQ�”����NJ��
90 mg adolescents
(>40 kg)
methylphenidate chew tabs
(Quillichew ER chew tabs)
20, 30, 40 mg
chewable tabs 12 hours
20 mg once daily
(titrate by 10 mg/week) FDA: 60 mg
methylphenidate susp (Quillivant
XR)
5 mg/mL suspension
(fruit flavored)
12 hours
20 mg once daily
(titrate by 10 mg/week) FDA: 60 mg
^ FDA approved for treatment of ADHD, * Generic product, §Oral long acting methylphenidate products have immediate release and extended release
components. Vary by product
.
Medications which can be sprinkled on food
- methylphenidate (Ritalin LA)
- methylphenidate (Metadate CD)
- methylphenidate (Aptensio XR)
- dexmethylphenidate (Focalin)
- amphetamine (Adderall)
- dextroamphetamine (Dexedrine
spansules)

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28

Amphetamine Products
Product Names Strengths Available Duration of Action
Usual Dosing
(titrate every 7 days,
Unless otherwise noted)
Maximum Dose
Short acting
dextroamphetamine tabs* (Dexedrine)


dextroamphetamine tabs (Zenzedi)
5, 10 mg tabs
1 mg/mL solution

2.5, 5, 7.5, 15, 20, 30
mg tabs
4-6 hours
2.5 -15 mg two to three times
daily. Titration 2.5 mg/week
(3-5 years),
��PJ�ZHHN��•���\HDUV�
FDA: 40 mg
Off label: 60 mg
(>50 kg)
amphetamine sulfate* (Evekeo) tabs 5, 10 mg tabs 4-6 hours 2.5 mg Titrate by 2.5 mg weekly FDA: 40 mg
Intermediate
acting
dextroamphetamine SR caps*§
(Dexedrine spansules)
bimodal release with immediate and
delayed onset
5, 10, 15 mg caps 6-8 hours 5-15 mg 2 times twice daily Titration 5 mg
FDA: 40 mg
Off label: 60 mg
(>50 kg)
amphetamine mixed salts tab
^combo*§ (Adderall) *§
5, 7.5, 10, 12.5, 15, 20,
30 mg tabs 5-8 hours
52.5-30 mg
1-2 times once or twice daily
Titration 2.5-5 mg once
or twice daily
FDA: 40 mg
Off label: 40 mg
�”���NJ������PJ�
(>50 kg)
Long acting
amphetamine mixed salts caps^*
combo (Adderall XR)*
5, 10, 15, 20, 25, 30
caps
10 hours
10-30 mg once daily
Titration 5-10 mg
FDA: 30 mg
Off-label: 30 mg
�”���NJ���
60 mg (>50 kg)
lisdexamfetamine (Vyvanse) caps^§ 20, 30, 40, 50, 60,
70 mg capsule
10-12
hours
20-70 mg once daily
Titration 10-20 mg daily FDA: 70 mg
dextroamphetamine/amphetamine
biphasic tab (Adzenys XR ODT)
3.1, 6.3, 9.4, 12.5,
15.7, 18.8 mg ODT 9-14 hours Titrate 3.1 mg weekly FDA: 18.8 mg
dextroamphetamine/amphetamine XR
oral suspension (Dyanavel) 2.5 mg/mL
10-12
hours
2.5-5 mg every am
Titrate every 4-7 days FDA: 20 mg
^ FDA approved for treatment of ADHD, * Generic product, §Oral long acting amphetamine products have immediate release and extended release
components. Vary by product





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29

GENERAL CONSIDERATIONS FOR NON-STIMULANTS
ξ Despite lack of FDA approval for age < 6 years, there is potential benefit in a
cohort of patients less than age 6; use may be considered in selected
populations.62-65 Consultation with Pediatric Psychiatry is strongly
encouraged for children under 6 years of age.
ξ Consider initiation with lower doses to improve tolerability
ξ Medication of choice if concern about abuse or diversion
ξ Monitor patient weight and vital signs
ξ Can be used in patients with history of tics or worsening of tics from
stimulants
ξ Sedation can occur with atomoxetine, clonidine and guanfacine
ξ Avoid bupropion if history of seizure disorders
ξ Taper off to avoid rebound hypertension for clonidine or guanfacine
ξ Consider cardiovascular risk factors before initiating tricyclics,
atomoxetine, bupropion, guanfacine
ξ Monitor closely for behavioral side effects including suicidal ideation
with atomoxetine and bupropion (see Black Box Warning)
ξ Guanfacine and clonidine may be used as adjunctive therapy with
stimulants.

Non-Stimulant Products
Product Names Strengths Available
Duration of
Action
Usual Dosing
(titrate every 7 days, until
otherwise indicated)
Maximum Dosing
Anti-depressants
bupropion* (Wellbutrin) tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
75, 100 mg tabs 4-5 hours
3 -6 mg/kg/day (or 150 mg ± 300 mg,
whichever is lowest)
Divide into 2 or 3 daily doses
6 mg/kg/day (or 300 mg
Whichever is lowest)
Divide into 2 or 3 daily
doses
bupropion SR* (Wellbutrin SR)
tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
100, 150, 200 mg
tabs
12 hours
3 -6 mg/kg/day (or 150 mg ± 300 mg,
whichever is lowest)
Divide into 2 daily doses.
6 mg/kg/day (or 300 mg,
whichever is lowest)
Divide into 2 daily doses.
bupropion XL* (Wellbutrin XL)
tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
150, 300 mg tabs 24 hours 3 -6 mg/kg/day (or 150 mg ± 300 mg, whichever is lowest)
6 mg/kg/day (or 300 mg
Whichever is lowest)
Norepinephrine
reuptake inhibitor
atomoxetine^ (Strattera) caps 10, 18, 25, 40, 60,
80, 100 mg caps
At least 10-
12 hours
����PJ�NJ�GD\��”���NJ���RU����PJ�GD\
(>70 kg) to 1.4 mg/kg/day �”���NJ��RU
100 mg/day (dose given once or twice
daily)
Titration: after 3-4 days
)'$������PJ�NJ�G��”�
70kg),
children/adolescents;
100 mg/day (>70kg)
*Generic product
^ FDA Approved


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30

Alpha-agonists
clonidine ER*^ (Kapvay) tabs 0.1mg ER tabs At least 10-
12 hours
0.1-0.4 mg/day
Titration: 0.1 mg FDA: 0.4 mg
clonidine* (Catapres) tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
0.1, 0.2, 0.3 mg tabs At least 4-6
hours
0.05 mg
DW�EHGWLPH�����PJ��•����NJ�
Titrate by 0.05 mg (<45 kg) or 0.1 mg
�•����NJ��LQFUHPHQWV�WR�WZLFH�GDLO\�
three times daily, four times daily
0.2 mg (27 ± 40.5 kg)
0.3 mg (40.5-45 kg)
0.4 mg (>45 kg)
guanfacine* (Tenex) tabs

Not FDA approved for ADHD-
consider consult to Pediatric
Psychiatry
1, 2 mg tabs 6-8 hours
0.5 mg at bedtime (<45 kg),
��PJ�DW�EHGWLPH��•����NJ�
Titrate by 0.5 mg (<45 kg) or 1 mg
�•����NJ��LQFUHPHQWV�WR�WZLFH�GDLO\�
three times daily, four times daily
2 mg (27±40.5 kg)
3 mg (40.5- 45 kg)
4 mg (>45 kg)
guanfacine ER^* (Intuniv) tabs 1, 2, 3, 4 mg ER
tabs
At least 10-
12 hours
1-4 mg once daily
(or 0.05-0.12 mg daily) Titration: 1 mg FDA: 4 mg
*Generic product
^ FDA Approved

Potential Harms: Side Effects of Pharmacotherapy
ξ The U.S. Food and Drug Administration (FDA) and its Pediatric Advisory Committee have reviewed data regarding psychiatric adverse events to
medications for the treatment of attention deficit/hyperactivity disorder (ADHD). For each agent examined (all stimulants, atomoxetine), there were
reports of rare events of psychotic symptoms, specifically involving visual and tactile hallucinations of insects. Symptoms of aggression, suicidality
(but no completed suicides), and cardiovascular issues were also reported.
ξ Stimulants: The most common side effects include appetite decrease, weight loss, insomnia, or headache. Less common side effects include tics
and emotional lability/irritability, liver toxicity, hypertension, cardiac arrhythmia and psychosis.
ξ Atomoxetine: Side effects of atomoxetine that occurred more often than those with placebo include gastrointestinal distress, sedation, and
decreased appetite.
ξ Bupropion may cause mild insomnia or loss of appetite. The highest recommended dose of bupropion is 450 mg. Higher doses may increase the
risk of seizure.
ξ Alpha- agonists: Side effects of alpha-agonists include sedation, dizziness, and possible hypotension. Abrupt discontinuations of alpha-agonist are
to be avoided.
ξ Combinations of Medications: There have been four deaths reported to the FDA of children taking a combination of methylphenidate and
clonidine, but there were many atypical aspects of these cases.
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31


Appendix E. ADHD HEDIS Measure


Follow-Up Care for Children Prescribed ADHD Medications (ADD)

The percentage of children newly prescribed ADHD medication who had at least 3 follow-up
care visits within a 10-month (300 day) period, one of which was within 30 days of when the first
ADHD medication was dispensed. Two rates are reported:

ξ Initiation Phase –Percentage of members, 6-12 years of age, who had 1 follow-up visit with
a prescribing practitioner within 30 days of starting the medication
ξ Continuation and Maintenance (C&M) Phase –Percentage of members, 6-12 years of
age, who remained on the medication for at least 210 days (allowed 90 gap days, so look at
300 days total to find 210 days on Rx) and who had at least 2 additional follow-up visits with
a practitioner within 270 days (9 months) after end of Initiation phase. One of these two
contacts (during days 31-300) may be by telephone with an MD, PA or NP (not RN or LPN).

Member must not have filled a prescription for an ADHD medication within 120 days (4 months)
prior to current prescription.

It is okay to switch between ADHD medications, as long as meets rules for continuous
treatment, as noted above.


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