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When ADHD gets complex

Presentation for Ron Joyce Children's Health Centre Rounds sharing the SDBP guideline for Complex ADHD

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When ADHD gets complex

  1. 1. When ADHD gets complex Olaf Kraus de Camargo @DevPeds Credit: SDBP slides by Michele Ledesma, MD
  2. 2. Outline § Example § CPS Statement § ADHD Research § Complex ADHD Guideline (SDBP) and how it applies to case § Application to RJCHC case load
  3. 3. March 2020 § Current concerns: § 6 yo girl, comes with grandmother who is caregiver § Concerns with learning and applying knowledge as she is seen as forgetful and often busy, moving from task to task § Teacher believes she is behind her peers in terms of reading and writing, and is difficult to teach due to lack of focus § Her toileting and hygiene behaviour is concerning as she often is found to be unhygienic with feces found in her clothing or on a toilet seat (one incident mentioned where feces was found smeared on the walls of the bathroom) § Often is found having hurt other children in class or having hurt her own sister
  4. 4. Conners - Teacher The Inconsistency Index score (raw score = 9, number of differentials ≥ 2 = 2) indicates that responses to similar items showed high levels of inconsistency. Scores may not accurately reflect the individual due to a careless or unusual response to some items.
  5. 5. Conners - Grandmother The Inconsistency Index score (raw score = 8, number of differentials ≥ 2 = 2) indicates that responses to similar items showed high levels of inconsistency. Scores may not accurately reflect the individual due to a careless or unusual response to some items.
  6. 6. CPS – ADHD - Diagnosis 1. “Symptoms are severe, persistent (i.e. present before 12 years of age and continuing > 6 months), and inappropriate for the patient’s age and developmental level” 2. “Symptoms are associated with impairment in academic achievement, peer and family relations and adaptive skills” Bélanger SA,Andrews D, Gray C, Korczak D. ADHD in children and youth: Part 1 - Etiology, diagnosis, and comorbidity. Paediatr Child Heal. 2018;23(7):454-461. doi:10.1093/pch/pxy110
  7. 7. CPS – ADHD - Process 1. Schedule several office visits to complete the diagnostic evaluation 2. Obtain detailed information on prenatal/perinatal events, medical and mental health history 3. Obtain developmental/behavioural history Bélanger SA,Andrews D, Gray C, Korczak D. ADHD in children and youth: Part 1 - Etiology, diagnosis, and comorbidity. Paediatr Child Heal. 2018;23(7):454-461. doi:10.1093/pch/pxy110
  8. 8. CPS – ADHD - Process 4. Evaluate family medical and mental health needs, family functioning and coping styles of primary caregivers.Ask about genetic disorders 5. Evaluate for comorbid disorders (psychiatric, neurodevelopmental and physical) 6. Review academic progress 7. Obtain standardized behaviour rating scales Bélanger SA,Andrews D, Gray C, Korczak D. ADHD in children and youth: Part 1 - Etiology, diagnosis, and comorbidity. Paediatr Child Heal. 2018;23(7):454-461. doi:10.1093/pch/pxy110
  9. 9. Findings in March 2020 §History: §There may have been prenatal exposure to crystal meth, alcohol, cocaine §Girl received services for speech delay when she was little §Grandmother believes that there has been exposure to sexually explicit content and physical abuse between parents.There is also a concern that the children were given access to cocaine at a younger age by the biological mother
  10. 10. Findings in March 2020 §Family History: § Strong family history of Learning Disability,ADHD, Intellectual Disability,Tic Disorders, "Rage Disorder", Sleeping Disorder
  11. 11. Findings in March 2020 §Supports in school environment: §No services in place to help her focus at school (IEP or EA)
  12. 12. Findings in March 2020 §Supports in home environment: § A sister (who was also assessed and presents with similar issues) and paternal aunt (who has an intellectual disability) in the home, along with 10 dogs (multiple adult dogs and multiple puppies). CAS is involved and has concerns about the cleanliness of the house. § No services in place to help grandmother with behavioural challenges of 2 girls that have been exposed to a series of stressors over the last 6 years and might present with FASD/ACE’s
  13. 13. Findings in March 2020 §Physical Exam & Observation: § Normal physical exam, 2 of 3 sentinel facial features for FASD § Compliant, friendly, not restless during consult
  14. 14. CPS – ADHD - Diagnosis Bélanger SA,Andrews D, Gray C, Korczak D. ADHD in children and youth: Part 1 - Etiology, diagnosis, and comorbidity. Paediatr Child Heal. 2018;23(7):454-461. doi:10.1093/pch/pxy110
  15. 15. CPS – Recommendations §Co-morbid ASD, ID, prematurity? §Does not fulfil diagnostic criteria for any of those §“Coordinated therapies help to lower the medication dose required and minimize risk for adverse effects.” Clark B, Bélanger SA.ADHD in children and youth: Part 3-Assessment and treatment with comorbid ASD, ID, or prematurity. Paediatr Child Heal. 2018;23(7):485-490. doi:10.1093/pch/pxy111
  16. 16. CPS – ADHD - Treatment § Non-pharmacologic interventions 1. Psychoeducation 2. Shared decision-making 3. Parent Behaviour Training 4. Classroom Management 5. Daily Report Card 6. Behavioural Peer Interventions 7. Organizational Skills Training 8. Exercise § Pharmacologic interventions 1. Stimulants 2. Non-stimulants Feldman ME, Charach A, Bélanger SA.ADHD in children and youth: Part 2—Treatment. Paediatr Child Heal. 2018;23(7):473-484. doi:10.1093/pch/pxy114
  17. 17. CPS – Recommendations 1. “Treatment approaches for children and youth with ADHD and comorbidities must be multimodal and part of an individualized, comprehensive care plan.A psychoeducational plan of interventions should be initiated first, combined with other nonpharmacological interventions and medication when indicated, always keeping specific functional or behavioural goals in mind.” Feldman ME, Charach A, Bélanger SA.ADHD in children and youth: Part 2—Treatment. Paediatr Child Heal. 2018;23(7):473-484. doi:10.1093/pch/pxy114
  18. 18. CPS – Recommendations 2. “Medication use should be reserved for children and youth diagnosed with ADHD whose learning or academic performance are impaired by attention difficulties or whose behaviours and social interactions are impaired by lack of impulse control and hyperactivity.” Feldman ME, Charach A, Bélanger SA.ADHD in children and youth: Part 2—Treatment. Paediatr Child Heal. 2018;23(7):473-484. doi:10.1093/pch/pxy114
  19. 19. CPS – Recommendations 3. “When initiating treatment with ADHD medication, set goals or target outcomes focused on symptom reduction and improved functioning to guide the treatment plan.” Feldman ME, Charach A, Bélanger SA.ADHD in children and youth: Part 2—Treatment. Paediatr Child Heal. 2018;23(7):473-484. doi:10.1093/pch/pxy114
  20. 20. Plan in March 2020 § Refer to behavioural services due to described challenges in the home environment and overwhelmed grandmother ØServices for BT declined due to lack of diagnosis of ID ØReferral to Contact Hamilton What about meds?
  21. 21. ADHD - Research Pelham WE,Altszuler AR. CombinedTreatment for Children with Attention-Deficit/ Hyperactivity Disorder: Brief History, the Multimodal Treatment for Attention-Deficit/Hyperactivity Disorder Study, and the Past 20Years of Research. J Dev Behav Pediatr. 2020;41(2):S1-S11. What about different dosages? With behaviour therapy less medication is required
  22. 22. ADHD - Research Pelham WE,Altszuler AR. CombinedTreatment for Children with Attention-Deficit/ Hyperactivity Disorder: Brief History, the Multimodal Treatment for Attention-Deficit/Hyperactivity Disorder Study, and the Past 20Years of Research. J Dev Behav Pediatr. 2020;41(2):S1-S11. In what order and which combination should we treat?
  23. 23. ADHD - Research Pelham WE,Altszuler AR. CombinedTreatment for Children with Attention-Deficit/ Hyperactivity Disorder: Brief History, the Multimodal Treatment for Attention-Deficit/Hyperactivity Disorder Study, and the Past 20Years of Research. J Dev Behav Pediatr. 2020;41(2):S1-S11. Better start with BT!
  24. 24. < 4 years Presentation at age > 12 years Age Complex ADHD Developmental/learning issues Medical diagnoses Psychiatric diagnoses Co-occurring conditions Moderate to Severe Functional Impairment Diagnostic uncertainty Inadequate response to treatment Any of the following:
  25. 25. What about your clients?
  26. 26. Complex ADHD Children and adolescents with ADHD can have moderate-to-severe impairment across settings • Academics • Family functioning • Peer relationships • Extracurricular activities Approximately 1/2 to 2/3 will have a co-occurring condition
  27. 27. Complex ADHD Guideline: Highlights A focus on functional impairment to improve long term outcomes A focus on evidence-based psychosocial interventions as the foundation of treatment for complex ADHD
  28. 28. Complex ADHD Guideline: Highlights Shared decision making and clinical judgement Interprofessional care Comprehensive assessment, including psychological testing and mental health diagnostic assessment Multimodal treatment, including treating co- occurring conditions A life-course perspective
  29. 29. MANAGEMENT Evidence-based behavioral and educational interventions are the foundation of treatment. These address key functional domains (behavioral, educational, social) in home, school, and peer settings that are associated with improved long-term outcomes.
  30. 30. MANAGEMENT Developmentally-appropriate strategies for self- management, skill building, and prevention of adverse outcomes should be incorporated: • Behavior parent training (BPT) • Behavioral classroom management (BCM) • Behavioral peer intervention (BPI) • Organizational skills training for older children
  31. 31. MEDICATION MANAGEMENT COMBINED INTERVENTION WITH MEDICATION MANAGEMENT IS OFTEN INDICATED Clinicians should consider both symptoms and functional impairment. • Treatment goals should focus on functional impairment, not solely on symptom reduction. For significant co-occurring conditions, particularly mental health diagnoses, clinical judgment should be used to select treatment based on the symptoms that most impact functioning.
  32. 32. PROCESS-OF-CARE ALGORITHMS Behavioral/Educational Treatment (age ≥ 6 years) General Medication Treatment (age ≥ 6 years) Preschool General Medication Treatment (age 3-6y)
  33. 33. PROCESS-OF-CARE ALGORITHMS ADHD + Autism ADHD + Tics ADHD + Anxiety ADHD + Disruptive Behavior Disorders ADHD + Depression ADHD + Substance Use Disorder
  34. 34. ADHD and Coexisting Disruptive Behavior Disorders Child with ADHD and Disruptive Behaviors Disorder (DBD) • Evaluate current services and supports, ensure that basic behavioral/educational treatment has been implemented (see Behavioral/Educational Treatment of Complex ADHD Algorithm) • Implement intensive, evidence-based behavioral treatment (e.g., multi-systemic therapy, wrap-around services, intensive special education supports and setting • Monitor response Is impairment from DBD severe? • Adapt high intensity behavioral treatment if necessary or return to basic behavioral/educational interventions • Consider pharmacological treatment (see Complex ADHD General Medication Treatment Algorithm) To Behavioral/Educational Treatment of Complex ADHD Algorithm Yes Yes No Is impairment from DBD still severe? • Continue intensive behavioral treatments and supports • Go to Behavioral/Educational Treatment of Complex ADHD Algorithm. No Barbaresi WJ, Campbell L, Diekroger EA, et al. The Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder: Process of Care Algorithms. J Dev Behav Pediatr. 2020;41 Suppl 2S:S58-S74. doi:10.1097/DBP.0000000000000781
  35. 35. MANAGEMENT Communication and coordination of care among all professionals involved in the treatment and management of children and adolescents with complex ADHD is of utmost importance. Interventions often require targeted referral to behavioral health providers.
  36. 36. LONG-TERM CARE ONGOING, SCHEDULED MONITORING THROUGHOUT THE LIFE SPAN Preparing for key developmental transitions ADHD symptom severity Symptoms of co-existing conditions Functional impairment Standardized questionnaires 2-4x/year Screening for emerging co-existing conditions at least annually
  37. 37. LONG-TERM CARE MEDICATION MANAGEMENT Monitor therapeutic & side effects of medications within the first 30 days Medication management visits at least every 3-4 months Review anthropometric measures & cardiovascular indices that can be affected by medication
  38. 38. Status October 2020 § Contact Hamilton called once in the summer and then did not connect anymore § Behaviours escalating at home § Report card from grade 1 (6 years): § “completes tasks when 1:1 support. Knows five letters of the alphabet and one sound, some understanding of numbers, counts to 20, skipping 13 and 15, can represent quantities using blocks up to 7. Often refuses to participate in Gym.” § Still no services at home or at school Over 4 years in the “System”!
  39. 39. Complexities § Complex presentation of ADHD § Breakdown of interprofessional communication and collaboration § Siloed service structures § Funding-centred services X Family-centred care (needs-based)
  40. 40. Case Load RJCHC – “ADHD” § 2019-2020: § About 600 children and adolescents with ADHD (DPR + CYMH) § Medication management every 4 months: § Need for 1800 visits w/nursing and/or physician § One full-time physician has about 360 FU spots/year ØGuideline-conforming ADHD management would require 5 full-time staff only for medication management
  41. 41. Case Load RJCHC – “ADHD” § 2019-2020: § about 600 children and adolescents between DPR and CYMH § Behaviour management: § Ex. BPTG@HOME: 15 home visits/family/year – 50% of patients § Need for 4500 visits with therapists (BT and/or SW) ØGuideline-conforming ADHD management would require ?? full-time staff only for behavioural management (if one staff offers about 900 visits/year – 10 staff) Nobel E, Hoekstra PJ,Agnes Brunnekreef J, et al. Home-based parent training for school-aged children with attention-deficit/hyperactivity disorder and behavior problems with remaining impairing disruptive behaviors after routine treatment: a randomized controlled trial. Eur Child Adolesc Psychiatry. 2020;29(3):395-408. doi:10.1007/s00787-019-01375-9
  42. 42. Solutions § Focus on funding clinical staff § Improve collaboration with community-based services and schools § Obtain synergies from joint documentation across service providers (patient-owned health record) § Monitor and assess behaviours and side-effects online for time- efficient and targeted actions
  43. 43. Example -eHealth
  44. 44. Q & A Session Q A& ThankYou!

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