Stony Brook Children’s Pediatric Primary Care Clinic Curriculum
ADHD
June 2017
Cases developed by Susan Walker, MD, FAAP
Goal: To understand the diagnosis and management of ADHD in children aged 4-18 years.
Objectives:
1. Know the criteria for making the diagnosis of ADHD
2. Understand the different management options for ADHD
3. Discuss the side effects of ADHD medications
4. Plan the follow up of a child with ADHD
To do:
1. Read the following articles, paying special attention to the algorithm, table 2, and table 3 in the supplemental article:
“ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention Deficit/Hyperactivity Disorder in Children and Adolescents” Pediatrics 2011:128:1007 (Note: this guideline was reaffirmed in 2016)
“Supplemental Information: Implementing the Key Action Statements: An Algorithm and Explanation for Process of Care for the Evaluation, Diagnosis, Treatment, and Monitoring of ADHD in Children and Adolescents”
Both articles may be accessed from the following link:
http://www.aappublications.org/content/early/2011/10/17/aapnews.20111017-1
2. Answer the following questions about James before arriving at your clinic session:
An active preschooler
James is a four-year-old boy who presents to your office with his mother with a chief complaint of “he never slows down.” James has “always” been a very active child, according to his mother. Since starting preschool 4 months ago; he has been having some difficulty listening; his teacher has expressed concerns that James often interrupts her and has a difficult time taking turns. He seems to be well liked by his peers in class, and has been meeting all educational goals for pre-school. Based on the history thus far, does James meet the criteria for ADHD? (See Supplement table 2) What criteria must he meet to establish the diagnosis?
What is the recommended treatment for ADHD in a child aged 4-5? Is medication ever indicated? If so, in what circumstances?
An unfocused 4th grader
James returns for his 10-year well visit. He has been struggling in school and his mother would like your opinion about what can be done to help him. She tells you that James can’t sit still in class and takes an “enormous” amount of time to do his homework. His grades have been suffering as a result. He has difficulty taking turns in games and therefore many of his friends don’t like to play with him any more. What should you do to help establish the diagnosis of ADHD at this point?
James returns two weeks later with his parent and teacher assessment forms. He meets 6 out of 9 criteria for inattention and 8 out of 9 criteria for hyperactivity/impulsivity on both the teacher and parent forms. He is doing poorly in math and reading. Does James meet the criteria for ADHD now?
His mother asks you what can be done for his attention problems. What are the recommendations for ADHD treatment in this age group?
James has been receiving support at school and is still struggling. Together with James and his mother, you decide that a trial of medication is warranted. How do you decide what dose of medication to start with?
What information must be carefully obtained before beginning stimulant medication?
His mother asks you what side effects she might expect from the medication. How do you reply?
When should you see James in follow up after starting the medication? What are should you assess at this visit?
James returns for his scheduled follow up. He is functioning better in school and is able to complete his homework in a timely manner. He is not hungry for lunch, but is receiving his medication after eating a sizable breakfast. His weight is unchanged from the previous visit. You decide together to keep James on the current dose of medication and follow him every three months to check his weight and to monitor for side effects.
A teen in trouble
James schedules a visit to see you just prior to his 15th birthday. He is concerned that he might need in increase in medication. Over the past few months, he had noticed an increase in his distractibility when doing his homework, and has been “daydreaming” during class. What should you assess before increasing his medication?