Promoting early identification and partnerships between families, primary health care providers & the community

Distributed by: Snohomish Health District
Contributors: the University of Washington, Center on Human Development & Disability (CHDD) & the Washington State Department of Health (DOH).
Issue author and editor: Sophie Lu, MN, ARNP, Developmental Pediatric Nurse Practitioner, UW CHDD.
Reviewers: Samuel Zinner, MD Professor, Pediatrics, UW, Seattle. Emily Winn, DNP, ARNP, PPCNP-PC, PMHS, Woodcreek Pediatrics - Mary Bridge Children's.

Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common neurodevelopmental disorder in the pediatric population, with an estimated prevalence of 7-8%. The median age at diagnosis is 7 years. ADHD is more than twice as likely to be diagnosed in males than in females. Additionally, 6 in 10 children with ADHD have "complex ADHD", characterized as ADHD plus one or more other identified medical, psychiatric, developmental/learning co-occurring conditions that adversely affect their functioning at home, school, with peers, and in the community. Two clinical practice guidelines are now available to guide primary care and subspecialty clinicians in identifying, diagnosing, and managing ADHD and complex ADHD, including an updated ADHD guideline by the American Academy of Pediatrics (AAP) published in October 2019, and a complementary Complex ADHD guideline by the Society for Developmental & Behavioral Pediatrics (SDBP) published in February 2020.

What's New in the Updated Clinical Practice Guidelines?

The AAP diagnosis and management recommendations are similar to those of its previous guideline version, published in 2011. However, the new AAP guideline highlights the most common co-occurring conditions and emphasizes screening for them. Many of these conditions share ADHD symptoms, which can make them difficult to detect and diagnose. Because the management for ADHD differs from the management for these conditions, it is crucial to screen at the time of initial evaluation and periodically thereafter. The SDBP Complex ADHD guideline provides more specific direction. Co-occurring examples include:

emotional or behavioral conditions (e.g., anxiety, depression, oppositional defiant disorder, conduct disorders, substance use, history of trauma, and toxic stress)
developmental conditions (e.g., learning and language disorders, autism spectrium disorders)
physical conditions (e.g., tics, sleep apnea)

Spotlight on Equity: Racial and Ethnic Health Disparities

ADHD prevalence appears to be the same across ethnic groups, yet African-American and Latinx children are less likely to be diagnosed than non-Latinx white children
The response to pharmacologic treatment also appears to be the same for African-American, Latinx, and non-Latinx white children. However, African-American and Latinx children are less likely to receive ADHD treatment.
Some of the influencing factors to these disparities are: financial and language barriers, cultural views regarding ADHD behaviors, and parental views and practices.
Primary care providers (PCPs) must understand these disparities and approach families with cultural humility in providing care. The Cultural Formulation Interview (CFI) is a clinical tool available to help clinicians diagnose and treat individuals using person-centered, culturally respectful communication.

What to Consider in Your Practice

Who should be evaluated?
Any child or adolescent age 4 to 18 years who presents with 1) academic or behavioral problems and 2) symptoms of inattention, hyperactivity, or impulsivity. Children under 4 or over 12 years who first present with symptoms may have Complex ADHD and require special consideration. ADHD runs in families, therefore, particular early and frequent attention to children with a family history of ADHD is warranted. Genetics is a big part of the story, but not the whole story. For example, among identical twins, when one twin has ADHD, there there is a 55-90% chance that the other twin does too. The child of a parent with ADHD has a 25% chance of having ADHD as well.

Criteria and Diagnosis

Diagnosis is based on DSM-5 criteria requiring ad persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.
There are 4 dimensions/subtypes of ADHD identified in the DSM-5:
- ADHD/I: primarily inattentive presentation
- ADHD/C: combined (inattentive + hyperactive-impulsive) presentation
- ADHD/HI: primarily hyperactive-impulsive presentation
- ADHD other specified and unspecified ADHD
Clinical Presentation - frequent patterns:
- Preschool age: hyperactive; impulsive; inflexible; may be aggressive with peers
- Elementary school age: struggles with listening in class; poor organizational skills; struggles with social interaction; difficulty functioning independently
- Adolescence: struggles with learning, attention, and executive functioning; may find academic demands overwhelming
The symptoms must occur in at least 2 settings (e.g., home, school, daycare). Information can be obtained from reports from parents/guardians, the child (if developmentally appropriate), teachers, other school personnel, and mental health clinicians who are involved in the child's or adolescent's care.
A descriptive summary list of ADHD rating scales can be found at CHADD's Clinical Practice Tools. The NICHQ Vanderbilt Assessment Scale can be downloaded from the AAP ADHD Resource Toolkit.

Sleep and ADHD

Poor sleep quality or an inadequate amount of sleep can manifest as inattention, impulsiveness, hyperactivity, and oppositional behaviors in children without ADHD.
Sleep problems also commonly occur in children with ADHD. One study revealed that children with ADHD have higher rates of daytime sleepiness compared to children without ADHD. Another study found that 50% of children with ADHD had signs of sleep-disordered breathing, compared to 22% of children without ADHD.
It's essential to evaluate for sleep behaviors when evaluating for ADHD and when providing ADHD management.

Treatment
Children ages 4-6 years
The first line of ADHD treatment is parent training in behavior management. If available, school-based behavioral interventions may also be implemented. When behavioral interventions do not provide significant improvement and the child continues to have serious problems, methylphenidate may be used.

Children and adolescents ages 6-18 years
The primary treatments include FDA-approved medications for ADHD along with parent training in behavior management and/or behavioral classroom interventions.

School-based behavioral interventions are typically designed and monitored through an Individualized Education Program (IEP) and/or a Section 504 plan.

Special Needs Information and Resources

Regional:

Advancing Integrated Mental Health Solutions (AIMS) Center

https://aims.uw.edu/targeted-condition/adhd

WithinReach Family Health Hotline

1-800-322-2588, 1-800-833-6388 TTD
http://www.parenthelp123.org
Spanish: http://www.parenthelp123.org/es/

Parent to Parent Support Programs of Washington

1-800-821-5927
https://arcwa.org/index.php/getsupport/parent_to_parent_p2p_programs

National:

Understood.org - Understanding ADHD in Your Child

https://www.understood.org/en/learning-thinking-differences/child-learning-disabilities/add-adhd/adhd-in-children

AAP ADHD Resource Toolkit for Clinicians

https://www.aap.org/en-us/pubserv/adhd2/Pages/kit/data/assessdxframe.html

U.S. Department of Education: Teaching Children With Attention Deficit Hyperactivity Disorder: Instructional Strategies and Practices

https://www2.ed.gov/rschstat/research/pubs/adhd/adhd-teaching_pg4.html

Centers for Disease Control and Prevention (CDC) ADHD

https://www.cdc.gov/ncbddd/adhd/index.html

Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)

https://chadd.org/ (general website)
https://chadd.org/for-professionals/clinical-practice-tools/ (clinical practice tools)

References

Alvarado, C., & Modesto-Lowe, V. (2017). Improving Treatment in Minority Children With Attention Deficit/Hyperactivity Disorder. Clinical Pediatrics, 56(2), 171-176. https://doi.org/10.1177/0009922816645517

Barbaresi WJ, Campbell L, Diekroger EA, Froehlich TE, Liu YH, O'Malley E, Pelham WE Jr, Power TJ, Zinner SH, Chan E. Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder. Journal of Developmental & Behavioral Pediatrics. 2020;41:S35-S37. https://doi.org/10.1097/DBP.0000000000000770

Centers for Disease Control (CDC). Data and Statistics About ADHD. https://www.cdc.gov/ncbddd/adhd/data.html

Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). ADHD and Sleep Disorders. https://chadd.org/about-adhd/adhd-and-sleep-disorders/

Coker, T.R., Elliott, M. N., Toomey, S. L., Schwebel, D. C., Cuccaro, P., Emery, S. T., Davies, S.L., Visser, S. N., & Schuster, M. A. (2016). Racial and Ethnic Disparities in ADHD Diagnosis and Treatment. Pediatrics, 138(3), 1-9. https://doi.org/10.1542/peds.2016-0407

Lecturio Medical. (2018, March 14). Attention-Deficit/Hyperactivity Disorder (ADHD) - Pediatrics [Video]. https://youtu.be/9ZUaDIxHqT4

Morgan, P.L., Staff, J., Hillemeier, M. M., Farkas, G., & Maczuga, S. (2013). Racial and Ethnic Disparities in ADHD Diagnosis From Kindergarten to Eighth Grade. Pediatrics, 132(1), 85-93. https://doi.org/10.1542/peds.2012-2390

National Sleep Foundation. ADHD and Sleep. https://www.sleepfoundation.org/articles/adhd-and-sleep

Wolraich ML, Hagan JF, Allan C, et al; Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactive Disorder. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019;144(4):e20192528. (2020). Pediatrics, 145(3). https://doi.org/10.1542/peds.2019-3997

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