This presentation done by Family resident R2 Any mistake "if there" is from the sources

1. Approaching child
with ADHD
Lamyaa Alghafli
R2

3. • Attention-
deficit/hyperactivity
disorder (ADHD) is the
most common
neurobehavioral
disorder of childhood
and among the most
prevalent chronic
health conditions
affecting school-aged
children.

4. • Primary care clinicians frequently are asked
by parents and teachers to evaluate a child
for ADHD; early recognition, assessment
and management can redirect the
educational and psychosocial development
of most children with ADHD.

5. • Clinical practices
during routine health
supervision, such as
asking questions
about the child's
behavior, may assist
in early recognition
of ADHD.

6. • (1) How is your child
doing in school?
• (2) Are there any
problems with learning
that you or the teacher
have seen?
• (3) Are you concerned
with behavior problems
in school, at home or
when your child is
playing with friends?

7. AAP Guideline Recommendations
• RECOMMENDATION 1
In a child six to 12 years of age who
presents with inattention, hyperactivity,
impulsivity, academic underachievement
or behavior problems, primary care
clinicians should initiate an evaluation for
ADHD
Strength of evidence:
Good
Strength of
recommendation:
Strong

8. • RECOMMENDATION 2
The diagnosis of ADHD requires
that a child meet the criteria for
ADHD in the Diagnostic and
Statistical Manual of Mental
Disorders, 5th ed. (DSM-V)
Strength of
evidence:
Good
Strength of
recommendation:
Strong

12. • Hyperactive and impulsive symptoms:
Observed by four
years
Increase during
three to four years
Peaking in seven to
eight years
Hyperactive
symptoms begin to
decline after seven
to eight years
By the adolescent,
they may be barely
discernible to
observers.
In contrast, impulsive symptoms usually persist
throughout life.

13. • Inattentive symptoms:
Not apparent until the child is
eight to nine years of age.

14. Case 1
• 5-year-old boy came into the clinic with his mother, he is the youngest
child in the family ( have 2 brothers)
• He cruelly bit, hit and kicked his 12-year-old brother and 17-year-old
sister. When mom attempted to discipline him, he screamed and
threatened his mother and then would do the exact opposite of what
she told him to do. He said things to his mother like, “I don’t love you
anymore and you can’t control me. I don’t want to live anymore.” Despite
his threats, he did not actually mean that he wanted to die, yet he would
use the expression to manipulate his mother.

15. • Mom was concerned because he constantly bit his nails, to the point of leaving
marks on the tips of his fingers, and he picked his nose all the time. He wet the
bed 4 nights a week.
• His behavioral problems were bleeding into the classroom and causing trouble at
school. He had difficulty learning and would get frustrated easily. He said things
like “I don’t want to go to school because I don’t like it.” He had trouble focusing
and would lose his concentration after a few minutes and would throw a temper
tantrum at school. He couldn’t follow instructions and would get distracted easily.
Mom reported that it was difficult to get him to sit still in his seat because he
would fidget, squirm, and was very impatient. It was as if he was always “on the
go” like he was “driven by a motor.” He frequently would get in trouble at school
because he could not wait his turn, and if another child had a toy he wanted he
would go over and take it from them.

16. • He craved eggs and would eat them 1-2 times a day. He also craved
ice-cold popsicles. He would chew the icy popsicles one after
another and if mom gave him an endless supply, he would eat them
all day long. At night it was very difficult to get him to go to sleep
because he would be wide-awake and want to play until at least
1am. When he finally fell asleep, he would kick off his covers and
tear off all his clothes because he would get hot. His mother
couldn’t discipline him because he would be so nasty back to her
and the teachers at school were telling her he needed to be on
methylphenidate.

17. • ADHD, predominantly hyperactive-impulsive type

18. Case 2
• Ten-year-old fifth grader with a history of problems in school. Teachers
reported his “approach to class work is very chaotic,” and he rarely could
focus on one task for longer than two to three minutes. His mother said
she had to “repeat instructions over and over.” His school performance was
getting worse each year. He wished he could get his school work in on time
and not be behind his classmates. His mother related the teacher’s concern
of his difficulty with verbal instructions, and her own concerns of him crying
over his homework, and falling down a lot. Throughout the evaluation he
was very cooperative although at times extremely lethargic.

19. • His birth had been traumatic. After 36 hours of labor, the doctors had
pulled him out so forcefully. He had sinus and ear infections frequently.
His mother reported that he achieved early development milestones. He
dislikes tight pants and tags in his shirt. He is also sensitive to some
smells.
• In clinic, he spent most of the time rolling around in the office chair. For
tasks like visual tracking, he propped his head up with both hands to keep
it still, and to allow his eyes to work without worrying about his body.
Even so, his head moved while his eyes tried to track. Whenever he was
asked to write or draw something his thumb always avoided contact with
the pencil. He also immediately shoved the paper and pencil away from
him as soon as he was completed with a given task, so he could clear the
surface for his arms, to again prop himself on the table.

20. • He was able to complete all the tasks, but had a delayed response time,
especially when multiple manipulations or sequencing was required. On
occasion, he felt that he could remember the item only if he could draw it.
• When given a series of nonsense syllables to repeat he had particular
difficulty accurately recalling syllables with the “K” sound. He
demonstrated a long delay in alphabetizing the names of five animals
without writing their names, although he had excellent recall for the
animals even half an hour after first working on the page where they were
drawn.

21. ADHD, inattentive type

22. • RECOMMENDATION 3
The assessment of ADHD requires evidence directly
obtained from parents or caregivers regarding the core
symptoms of ADHD in various settings, the age of onset,
duration of symptoms and degree of functional
Specific questionnaires and rating scales have been
developed. These instruments may not function as well in
the primary care clinician's office. In addition, questions on
which these rating scales are based are subjective; their
results may convey a false sense of validity.
Strength of
evidence:
Good
Strength of
recommendation:
strong

24. • RECOMMENDATION 3A
Use of ADHD-specific scales is a
clinical option when evaluating
children for ADHD.
• RECOMMENDATION 3B
Use of broadband scales is not
recommended in the diagnosis of
children for ADHD, although they
may be useful for other purposes.
Strength of
evidence:
Strong
Strength of
recommendation:
Strong

25. • RECOMMENDATION 4
The assessment of ADHD also
requires evidence directly obtained
from the classroom teacher (or other
school professional) regarding the
core symptoms of ADHD, duration of
symptoms, degree of functional
impairment and coexisting
conditions.
Strength of evidence:
Good
Strength of
recommendation:
Strong

26. • RECOMMENDATION 4A
Use of ADHD-specific scales is a
clinical option when diagnosing
children for ADHD.
• RECOMMENDATION 4B
Use of teacher global questionnaires
and rating scales is not
recommended in diagnosing
children for ADHD, although they
may be useful for other purposes.
Strength of
evidence:
Strong
Strength of
recommendation:
Strong

27. • RECOMMENDATION 5
Evaluation of the child with ADHD
should include assessment for
conditions
Other psychologic and developmental
disorders frequently coexist in children
who are being evaluated for ADHD.
Evidence for most coexisting disorders
may be readily detected by the primary
care clinician.
Strength of evidence:
Strong
Strength of
recommendation:
Strong

29. • RECOMMENDATION 6
Other diagnostic tests are not
routinely indicated to establish
the diagnosis of ADHD but may
be used for the assessment of
coexisting conditions.
Strength of
evidence:
Strong
Strength of
recommendation:
Strong

30. EVALUATION • Medical evaluation
Before initiating medications:

31. • Developmental and behavioral evaluation:

32. Educational evaluation:
The teachers who provide the information should have regular
contact with the child for a minimum of four to six months.
Coexisting disorders:
The evaluation for ADHD should include assessment for coexisting
behavior/emotional disorders including oppositional defiant
disorder, conduct disorder, depression, anxiety disorder, and
learning disabilities.

33. • Psychometric testing
The public school system is the best place to
perform psychometric testing (ie, intellectual and
academic testing).
Psychometric testing is not necessary in the
routine evaluation.
Children with learning, language, visual-motor, or
auditory processing problems can be difficult to
distinguish from those with ADHD.
Comprehensive neuropsychologic testing may
help to clarify the diagnosis
• Electroencephalography
Evidence is insufficient to support the use of qEEG
over clinical evaluation of symptoms.

34. DDx

37. Indication for referral
1-Intellectual
disability (mental
retardation)
2-Developmental
disorder (eg, speech
or motor delay)
3-Learning disability
4-Visual or hearing
impairment
5-History of abuse 6-Severe aggression 7-Seizure disorder
8-Coexisting learning
and/or emotional
problems
9-Chronic illness that
requires treatment
with a medication
that interferes with
learning
10-Children who
continue to have
problems in
functioning despite
treatment

38. Celebrities With
ADD/ADHD
Michael Phelps
Justin Timberlake
Howie Mandel
Paris Hilton

39. GENERAL PRINCIPLES
1- Care coordination
-It should be managed similar to other chronic conditions of childhood
by regularly monitoring the effectiveness of therapy.
-Primary care clinicians should provide information to the family about
ADHD, help the family set specific treatment goals, and offer
information regarding local support groups.
-Regular communication between the parents and the teachers can
occur through a daily report card or a weekly communication book.

40. 2- Involvement of patient and family
Behavioral interventions, medication,
school-based interventions, or
psychologic interventions.
Decisions regarding the choice of
should involve the patient and his or her
parents.
3- Target goals
Determined in collaboration with the
parents, child, and school personnel.
4- Treatment of coexisting conditions
One-third of children with ADHD have
one or more coexisting conditions.

41. MANAGEMENT
• Preschool children
(age 4 through 5 years)
Recommend behavior therapy.
The addition of medication (methylphenidate) to
behavior therapy indicated if target behaviors do not
improve with behavioral therapy and the child's
function continues to be impaired.
Comprehensive reevaluation during school years may
be warranted because it may no longer meet criteria
for ADHD after school entry or in the later school
years and it could have new diagnosis.

42. • School-age children
initial treatment with stimulant medication combined with behavioral
therapy to improve core symptoms and target outcomes
However, nonstimulant medications may be more appropriate for certain
children. Comorbid conditions must be considered in selecting treatment.
The values and preferences of the patient and family are critical factors in
deciding whether or not to initiate medication.
The decision of families who choose to decline medication must be
respected.
• Children who do not meet ADHD criteria
Behavioral interventions.

43. Monitoring
• Regularly for:
1- Adherence to the treatment plan
2- Adverse effects of therapy
3- Response to therapy
• Children who are not receiving medication
should be seen at least twice per year, particularly
during critical transitions (eg, into middle school).

44. The monitoring children receiving medication depends upon the stage of
pharmacotherapy.
Weekly during the titration stage
Every three or six months during the maintenance phase, depending upon
adherence, coexisting conditions, and the persistence of symptoms.

45. Response to treatment
By objective
measurement of
reduction in core
symptoms and
improvement in
target goals (eg, 40
to 50 percent
reduction in core
symptoms
compared with
baseline; decreased
proportion of
missing assignments
from 60 to 20
percent per week).
Core symptoms can
be monitored
through the use of
ADHD-specific
rating scales.
Target symptoms
can be monitored
through a daily
report card or
periodic narrative
reports from the
child's teacher.

46. Inadequate or lack of response to treatment may be due to:
●Coexisting conditions
●Nonadherence to the treatment plan
●Incorrect or incomplete diagnosis

48. TREATMENT MODALITIES
• 1- Behavioral interventions :
Modifications in the physical and social environment that are
designed to change behavior using rewards and nonpunitive
consequences.
Behavioral techniques that are used for children with ADHD
include:
1- Positive reinforcement
2- Time-out
3- Response cost (withdrawing rewards or privileges when
unwanted behavior occurs)
4- Token economy (a combination of positive reinforcement and
response cost)

49. Behavioral interventions are preferred as:
1- The initial intervention
for preschool children
with ADHD
2- adjuncts to medication
for school-aged children
and adolescents.
3- Children who do not
meet ADHD criteria
Most effective if parents understand the principles of behavior therapy and the
techniques are consistently implemented.

50. Behavior therapy and environmental changes that can be used by parents or
teachers:
Maintaining a
daily schedule
Keeping
distractions to a
minimum
Providing specific
places for child to
keep his toys,
clothes and
schoolwork
Setting small,
reachable goals
Rewarding positive
behavior
Identifying
unintentional
reinforcement of
negative
behaviors
Using charts and
checklists to help
the child stay "on
task"
Limiting choices
Finding activities in
which the child can
be successful
Using calm discipline

51. • 2- Pharmacotherapy:
First-line for school-aged children (≥6 years) and
adolescents.
Medications may be used as an adjunct to behavioral
interventions for preschool children (4 through 5 years)
who fail to respond to behavioral interventions alone.
• 3- Combination therapy:
In preschool children who do not respond to behavioral
interventions.
For school-aged children and adolescents who have a
suboptimal response to pharmacotherapy, have a
coexisting condition, or experience stressors in family life.

52. Provision of resource room
support, classroom
modifications,
accommodations, or
behavioral interventions
(may include sitting near
the teacher, having
extended time to complete
tasks….)
Studies demonstrated that classroom-
based programs to enhance academic
skills were effective in improving
achievement scores in multiple
domains, but the benefits were
sustained only as long as the
intervention is continued.
ADHD is considered to be a disability under
the Individuals with Disabilities Education
Act. Under IDEA, children with ADHD may
qualify for special education or related
services. Alternatively, they may qualify for
appropriate accommodations within the
regular classroom setting under Section 504
of the Rehabilitation.
4- School-based interventions:

53. • 5- Social skills training
Addressed through social skills groups or similar
(in or out of the school setting).
• 6- Psychotherapy interventions
Directed toward the child (rather than the parent or
environment) and designed to change the child's emotional
status (eg, play therapy) or thought patterns (eg, cognitive-
behavior therapy, cognitive therapy).
Have not been proven beneficial for the core symptoms of
ADHD in children.
It may be helpful in coexisting conditions or skill deficits. Play-
based interventions may improve social skills. Cognitive-
behavioral therapy may improve organizational/ planning
skills and coexisting psychiatric problems in adolescents and
may be a helpful adjunct to medications.

54. UNPROVEN
INTERVENTION
S
• 1- Physical activity:
At least 60 minutes of moderate to vigorous
activity per day is recommended for all children ≥6
years of age.
Study show that range of physical activities (eg,
yoga, team sports, aerobic activity, guided walks)
have been associated with improvement in the
core symptoms of ADHD with little risk of harm.
They also suggest that aerobic exercise improves
neurocognitive function and increases the
effectiveness of medications.
Additional studies are needed to determine which
types, duration, intensity, and frequency of exercise
are most effective.

55. • 2- Dietary interventions
• A- Elimination diets:
We generally do not suggest elimination diets for children
with ADHD.
Some experts suggest that a short (no more than five-
trial of an elimination diet may be warranted for certain
children (eg, those whose caregivers are concerned about
the side effects of medications).
The diet should be supervised by health care provider and
dietician.
If behavior improves during the diet, restricted foods can be
added back weekly, one component at a time, to identify
problematic foods that should be excluded from a less
restrictive permanent diet.
The long-term effects of dietary elimination on nutritional
status are unknown

56. • B- Essential fatty acid supplementation
We don’t suggest essential fatty acid supplementation to improve core symptoms.
Evidence that fatty acid supplementation improves core symptoms in children with ADHD is limited.
Fatty acid supplementation is unlikely to be harmful.
• 3- Mindfulness
Heightened or complete awareness of one's thoughts, emotions, or experiences on a moment-to-moment basis to increase
self-regulation.
Larger and more clinical studies are needed to determine the optimal patient population and approach.

57. • 4- Other alternative therapies:
Complementary and alternative medicine (CAM)
other than mentioned before.
It is important for primary care providers to ask their
patients whether they have tried any CAM therapies
for ADHD so that the risks and benefits of such
therapies can be discussed.
We do not routinely suggest these interventions for
children with ADHD.
Several alternative therapies, including chelation and
megavitamins, may have serious adverse effects.

58. Vision training
Megavitamins
Herbal and mineral supplements
Neurofeedback/biofeedback
Chelation
applied kinesiology

59. PROGNOSIS Derived from small cohort studies of male patients who
were evaluated and treated for ADHD in psychiatric
clinics .
Early and effective management and support may be
helpful in improving adult outcomes.
• 1- Injury and self-injury:
At greater risk for incurring intentional and unintentional
injury than other children.
Treatment with stimulant medications may mitigate this
risk.
ADHD was independently associated with increased
mortality in children, adolescents, and adults; most of
the deaths were caused by unnatural causes, particularly
unintentional injuries.

60. • 2- Driving:
Adolescents with ADHD are more likely to have MVA.
Driving performance improves with stimulant medication.
• 3- Education:
Impaired academic function (completion of less schooling, lower achievement scores, failure of
more courses) appears to persist, even in children who no longer meet criteria for diagnosis of
ADHD in adolescence or adulthood.
• 4- Substance use:
At risk of engaging in substance use during adolescence and adulthood, particularly if they
present with comorbid conduct disorder (CD) or oppositional defiant disorder (ODD).
The mechanism for the association is not clear.
Proposed theories include impulsivity, poor judgment, and biologic vulnerability.
The risk of engaging in substance use in adolescence or adulthood does not appear to be
by medication.

61. • 5- Persistence of symptoms:
Prevalence suggest that one to two thirds of the 3 to 10 percent of children
diagnosed with ADHD continue to manifest ADHD symptoms into adult life.
Factors associated with persistence of symptoms into adulthood include the
severity of initial symptoms, coexisting mental health disorders, and parental
health disorders.

62. • 6- Employment:
The rate of employment of ADHD
did not differ from that of controls.
Probands were reported to have lower
status jobs and to perform poorly
with controls when rated by other
employers.
• 7- Antisocial personality:
Children who have ADHD are at increased
risk to develop antisocial personality
disorder and behaviors in adulthood.

65. Resources