Source: Manual of Ambulatory Pediatrics 2010
SOAP Note
ADHD
ADHD
A neurodevelopment disorder, attention deficit hyperactivity disorder (ADHD) presents as a persistent pattern of inattention, hyperactivity, and impulsivity that is more frequent and severe than is typically observed in people at a comparable level of development (Diagnostic and Statistical Manual of Mental Disorders [DSMIV]). There is strong evidence of a genetic component.
Inattention, hyperactivity, and impulsivity—the core symptoms—must be observed before the age of 7 years and have been present for at least 6 months. Impairment of social, academic or occupational functioning must be evident in more than one setting. ADHD is diagnosed clinically since no objective tests exist to confirm the diagnosis.
I. Etiology
Underlying causes unknown but appear to be heterogeneous. Various environmental factors have been associated with the diagnosis.
Multiple possible etiologies are: Neuroanatomical/neurochemical Genetic Environmental CNS Insults
II. Incidence
A. 4%–12% of school children in US according to DSM-IV. Males are at an increased risk.
B. It frequently co-exists with other conditions. For example, Oppositional Defiant Disorder is present in 35%, conduct disorder in 26%, anxiety disorder in 26%, and depressive disorder in 18%.
C. Up to 80% continue symptomatic into adolescence and up to 60% into adulthood.
D. Siblings of children with ADHD are at greater risk.
III. Types
A. Inattentive
B. Hyperactive/impulsive
C. Combined inattentive/Hyperactive/Impulsive
IV. Subjective findings
A. Inattention:
1. Difficulty paying attention
2. Daydreams
3. Easily distracted
4. Forgetful
5. Careless
6. Disorganized
7. Does not want to do things requiring sustained attention or effort
B. Hyperactivity
1. In constant motion—squirms, fidgets, cannot sit still
2. Talks too much
3. Cannot play quietly
4. Continually “flits” from one activity to another
C. Impulsivity
1. Interrupts conversations and games
2. Cannot wait for turn
3. Answers before question completed
4. Acts without thinking—e.g., runs into street
D. Parents have difficulty with discipline or managing behaviors
E. Poor time management.
F. Room, desk, belongings in a state of chaos.
IV. Objective
A. DSM-IV Criteria for ADHD
1. Inattention: Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:
a. Does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b. Often has trouble keeping attention on tasks or play activities
c. Often does not seem to listen when spoken to directly
d. Often does not follow instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behavior or failure to understand instructions)e. Often has trouble organizing activities
f. Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework)
g. Often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools)
h. Is often easily distracted
i. Is often forgetful in daily activities
2. Hyperactivity-impulsivity: Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
Hyperactivity
a. Often fidgets with hands or feet or squirms in seat.
b. Often gets up from seat when remaining in seat is expected.
c. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
d. Often has trouble playing or enjoying leisure activities quietly.
e. Is often “on the go” or often acts as if “driven by a motor.”
f. Often talks excessively.
Impulsivity
a. Often blurts out answers before questions have been finished
b. Often has trouble waiting one’s turn
c. Often interrupts or intrudes on others (e.g., butts into conversations or games)
d. Some symptoms that cause impairment were present prior to 7 years of age.
e. Some impairment from the symptoms is present in two or more settings (e.g., at school/work and at home).
f. There must be clear evidence of significant impairment in social, school, or work functioning.
g. The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
V. Assessment
1. Diagnosis:
Assessment is based on the above criteria which is obtained by observation and evaluation of Connors questionnaires from parents and teachers or by the Vanderbilt rating scale (see Appendix O, p. 572).
There is no single diagnostic test. The diagnosis involves information from several sources and should be made following DSM-IV criteria.
a. ADHD, Combined Type: If both criteria from 1. and 2. have been met for the past 6 months. (Six or more symptoms of inattention and six or more symptoms of hyperactivity have been present.)
b. ADHD, Inattentive Type: If criterion from 1 has been met for the past 6 months. (Six or more symptoms of inattention have been present.)
c. ADHD, Hyperactive-Impulsive Type: If criterion 2 has been met for the past 6 months. (Six or more symptoms of hyperactivity/ impulsivity have been present.)
2. Rule Out Co-morbid Conditions
a. Oppositional defiant disorder: Loses temper easily, defiant, hostile, and intentionally annoying; estimated prevalence 35%
b. Anxiety: Fear, worry, panic; estimated prevalence 25%
c. Depressive disorder: Estimated prevalence 18%
d. Conduct Disorder: Estimated prevalence 25%
e. Learning disorders
VI. Treatment
1. Treatment is multifaceted and is predominantly pharmacotherapy with behavioral interventions, parent training, and school intervention. Dosage of medication should be started low and titrated upward. Seventy percent of children respond to the first stimulant prescribed. Approximately half who respond poorly will respond to second drug prescribed.
2. Stimulants
a. Long-acting stimulants
a. Concerta: 18-, 27-, 36-, or 54-mg extended-release tablets.
(1) 12-hour duration of action
(2) Immediate release at 22%
(3) Dose up to a maximum of 72 mg/d for adolescents
(4) Do not exceed 2 mg/kg/d
b. Focalin XR: 5-, 10-, 15-, or 20-mg extended-release capsules
(1) 12-hour duration of action
(2) Can be sprinkled
(3) Starting dose should be half the currently prescribed dose of other racemic methylphenidate HCL drugs.
c. Metadate CD: 10-, 20-, 30-, 40-, 50-, or 60-mg extended release capsules
(1) 8-hour duration
(2) Can be sprinkled
(3) Onset of action 1.5 hours after dosing.
(4) Maximum dose 60 mg/d
d. Ritalin LA: 10-, 20-, 30-, or 40-mg extended-release capsules
(1) 8-hour duration of action
(2) Immediate release at 50%
(3) Useful if increased hyperactivity in AM
(4) Can be sprinkled
(5) Maximum dose 60 mg/d
b. Intermediate Release Stimulants
a. Adderall: 5-, 7.5-, 10-, 12.5-, 15-, 20-, or 30-mg tablets
(1) First dose on awakening
(2) If needed, give 1 or 2 more doses at 4to 6-hour intervals.
(3) Maximum dose usually 40 mg/d in 2 or 3 divided doses
b. Adderall XR: 5-, 10-, 15-, 20-, 25-, or 30-mg extended-release capsules
(1) Give once daily in AM
(2) May be sprinkled
(3) Maximum dose 30 mg/d
c. Dexedrine: 5-mg tablets
(1) Give in AM
(2) Repeat dose every 4–6 hours prn
(3) Maximum dose: 40 mg in 2 or 3 divided doses
(4) May switch to Dexedrine Spansules once titrated
d. Dexedrine Spansules: 5-, 10-, 15-mg sustained-release capsules
(1) Used for once daily dosing once Dexedrine titrated
(2) Maximum dose 40 mg/d
c. Methylphenidate patch (Daytrana): 10-, 15-, 20-, and 30-mg transdermal patch
a. Slow release
b. Useful when child resistant to oral medication
c. Apply daily to alternating hip 2 hours prior to desired effect.
d. Remove after 9 hours. May remove earlier if shorter duration of effect desired or late day side effects.
e. Titrate at one-week intervals.
3. Non-stimulant
a. Atomoxetine
a. Start with 0.5 mg/d for 3–5 days.
b. Titrate up to 1.2–1.4 mg/kg/d
c. Use if intolerable side effects with stimulants, treatment failure, or if parents object to stimulant medication.
d. Follow-up on 4–6 weeks.
e. Contraindicated with monoamine oxidase inhibitors (MAOIs).
f. Concurrent use with albuterol, other beta-agonists, and over-the-counter (OTC) cough and cold preparations with pseudoephedrine may cause increases in blood pressure and heart rate.
4. Monitor academic progress.
a. Maintain contact with school personnel.
5. Monitor social relationships.
6. Monitor height, weight, blood pressure, and pulse on a regular basis.
7. Behavioral Therapy
a. Use in conjunction with medication.
b. Positive reinforcement
c. Time outd. Withdraw rewards or privileges for unwanted behavior.
e. Set reasonable goals.
8. Document baseline severity with parents and teachers.
VI. Education
A. Return for height, weight, blood pressure and pulse monitoring as scheduled.
B. Safety issues
1. Child is apt to be a “risk taker.”
2. Impulsivity and inattention can increase incidence of accidents.
3. Adolescents with ADHD are more prone to motor vehicle accidents.
C. Medication: It may take several trials to adjust the correct medication and dosage.
D. Atomoxetine
1. May take 3–6 weeks for effect
2. Use if parents object to stimulants
3. Consider use when sleep disturbance and/or significant early morning hyperactivity are problematic
E. Stimulant medication side effects
1. Decreased appetite
2. Potential for decreased growth
3. Nausea
4. Stomachaches
5. Fatigue
6. Mood swings
7. Tics
8. Stuttering
F. Administer medication with or after a meal.
G. Beads from sprinkled capsules should not be chewed.
H. Without treatment, child at-risk for
1. Disorganization in school work
2. Poor self-esteem
3. Risky behavior
4. Poor peer relationships
5. Increased incidence of depression, anxiety, and/or substance abuse.
I. Reassure parents that it is not “their fault.”
J. Maintain firm, consistent limits: Present a “united front.”
K. Reward positive behaviors.
L. Adhere to a daily routine. Advise child prior to change in routine.
M. Provide quiet place with minimal distractions for homework.
N. Behavioral therapy assists child in learning about responsibility and control over his or her behavior.
O. Anticipate problem settings: Make a plan, review rules, and establish incentive.
P. Make commands effective. State, don’t ask and go to child and maintain eye contact.
Q. Do not give multiple tasks and if task complex, divide into small steps.
R. Time outs for infractions should be limited in length.
S. ADHD generally continues into adulthood.
T. Recognize that a child with ADHD creates stress for parents.
U. Maintain open communication with schools. Discuss implementation of accommodations with teacher and administration. Daily behavior charts are effective as well.
V. Additional services can be obtained, if appropriate, through
1. IDEA (Individuals with Disabilities Education Improvement Act)
2. Section 504 (Rehabilitation Act of 1973)
3. ADA (Americans with Disabilities Act of 1990)
4. ESEA-NCLB 2001 (the Elementary and Secondary Education Act)
5. However, in itself, ADHD is not considered a learning disability.
W.Treatment for ADHD is long-term and will require ongoing communication and planning with child’s doctor, teacher, and others involved with the child.
VII. Follow-up
A. Telephone call every one to two weeks to check on medication response.
B. Recheck in office monthly until medication is adjusted and satisfactory progress is seen.
C. Further follow-up visits according to need based on school and social progress and expected outcomes.
D. Parent will need to come to office every month to get prescription for medication.
VIII. Consultation/referral
A. Children with cardiovascular abnormalities
B. Children under 7 years of age
C. Children with co-morbid conditions
BOOKS
American Academy of Pediatrics. (2004). ADHD: A complete and authoritative guide. Elk Grove Village, IL: Author.
Ashley, S. (2005). ADD and ADHD answer book. Naperville, IL: Sourcebooks, Inc.
Barkley, R. A. (2000). Information and guidance for parents in the management of children with ADHD. Taking Charge of ADHD: The Complete Authoritative Guide for Parents. New York: Guilford Publications.
Gordon, M. (1991). Jumpin’ Johnny get back to work! A child’s guide to ADHD/Hyperactivity.
Ages 5–10. DeWitt, NY: GSI Publications.
Hallowell, E., & Ratey, J. (2005). Delivered from distraction: Getting the most out of life with attention deficit disorder. New York: Random House Publishing Group.
Reif, S. F. (2005). How to reach and teach children with ADD/ADHD: Practical techniques, strategies, and interventions. Hoboken: NJ: John Wiley & Sons.
WEBSITES
National Institute of Mental Health. Telephone: 301-443-4513. Website: http://www.nimh. nih.gov
National Attention Deficit Disorder Association. Telephone: 847-ADHD-377. Website: http://www.add.org
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). Telephone: 800-233-4050. Website: http://www.chadd.org