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ADHD Treatment Guidelines: Scoring and Starting Pharmacotherapy

by Rhonda Lawes, PhD, RN

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    00:01 Hi, I'm Doctor Rhonda Lawes and this is a tool that you can use in your practice if you're considering starting pharmacotherapy for the treatment of ADHD.

    00:10 This is a way for you to score the ADHD symptoms and the criteria to know when it's appropriate to start medication.

    00:17 Now you'll see this is the Vanderbilt ADHD Diagnostic Rating Scale and you'll see it abbreviated as Vadrs.

    00:24 Now this assessment tool is specifically designed to assess a child's ADHD impairment in two distinct settings.

    00:32 You're going to look at both at school and in home.

    00:35 Now there's two sources of information.

    00:37 The first one are the parents and the second group is the teacher questionnaire.

    00:41 So on the parent questionnaire it's going to focus on the behaviors that the parent sees at home and in other non-school settings.

    00:48 That your goal is to get insights into the child's behavior within their family environment. Now the teacher questionnaire, when that's completed and you're evaluating it, it's going to focus on the behaviors that are specifically observed in the classroom. You're going to get insight into how ADHD symptoms manifest in a structured educational environment.

    01:08 Now, both of these should be incorporated in your final assessment of the client.

    01:12 Now the scoring. The responses on the scale are typically scored based on a Likert type scale. The higher scores indicate more severe ADHD symptoms.

    01:21 There's several options for behavioral interventions for ADHD in children.

    01:26 Now, the focus of these interventions is typically on providing structure consistency and positive reinforcement.

    01:33 So two of the big ones are a parent training program or behavioral therapy.

    01:38 Now in the parent training programs, this is where parents can learn strategies on how to manage their child's behavior and promote positive interactions with their child.

    01:47 In behavioral therapy, the child will learn specific skills and strategies to help manage their behavior and cope with challenges.

    01:55 Now there's other options such as environmental modifications, positive reinforcement, parent child interaction therapy, social skills training, etc..

    02:05 Now Now. Medications are usually reserved for children who do not improve with the behavioral interventions.

    02:11 Now, there's criteria in this tool for the initiation of pharmacotherapy in children and adolescents. Now first of all, think about the main factor in deciding whether to initiate pharmacological treatment is the severity of the ADHD symptoms.

    02:26 If they have low or moderate severity, they can be offered medication or pharmacological treatment. Starting medication to treat ADHD is associated with significant lower mortality, particularly for death due to unnatural causes like accidents or suicide.

    02:43 So if your parents are considering the pharmacological treatment, let them know that this is one of the positives of initiating pharmacological treatment.

    02:52 Now, when the ADHD diagnosis is confirmed after a complete assessment of the disorder, these are additional things you'll need to do.

    02:59 You want to do a comprehensive history and physical exam.

    03:02 Make sure you have baseline measurements of height, weight, blood pressure, and heart rate. You want to screen them for risk factors for bipolar disorder.

    03:10 Because if you use a stimulant medication and atomoxetine, these are associated with the development of mania or mixed episodes.

    03:18 Make sure to establish baselines for common adverse effects that are associated with the medication of choice.

    03:24 You're going to look at areas like what's the impact on their appetite? What about their sleep pattern? Are they having headaches and having any GI symptoms or abdominal pain? Now make sure the child is greater than or equal to four years of age.

    03:38 The fourth option is to make sure that you, as a provider, have taken the time that the caregivers understand and they are agreeable, and accept that medication is needed for this child in proper management.

    03:51 The fifth one, the school will need to agree to cooperate with medication administration and monitoring, particularly if the child or adolescent don't take their own medications in school. Number six there should be no previous sensitivity to the chosen medication. Seven make sure the child has normal vital signs, normal heart rate and blood pressure, and no known cardiac risk factors.

    04:14 Number eight. The child should not have any significant comorbid condition, such as seizures, tics, depression, or anxiety.

    04:23 And number nine. The issue of substance abuse and stimulant misuse and diversion.

    04:29 Make sure that you're aware of this potential among household members.

    04:33 Make sure this is not a concern, particularly for children who will be treated with immediate release stimulants.

    04:39 And for adolescent patients, you should assess them for substance use.

    04:45 We're going to wrap up this discussion for pharmacotherapy for adults with ADHD.

    04:50 For most adults with ADHD, the initial treatment recommendation involves a combination of medication management and cognitive behavioral therapy that targets executive dysfunction.

    05:00 Now, in ketamine are suggested as the initial pharmacological treatment over methylphenidate, with the following exceptions.

    05:06 If the client has a history of substance use disorder, then the first line treatment is the non-stimulant atomoxetine.

    05:14 Now, if it's co-occurring with depression, which is treated with bupropion, this is known to be effective for both ADHD and depression, so that bupropion may actually treat the depression and the ADHD.

    05:25 If the adult client experiences clinically significant symptoms despite the treatment with amphetamines, you may consider transitioning to a methylphenidate product if the patient is pregnant.

    05:37 Methylphenidate should be avoided when possible due to fetal risks, with amphetamines being preferred if the medication is necessary.

    05:45 If you have an adult client who has had a poor response or a lack of tolerance to two prior stimulants, here's the recommendation.

    05:53 Successive trials of atomoxetine bupropion or a tricyclic antidepressant such as nortriptyline, alongside augmentation with cognitive behavioral therapy.

    06:03 This is what's recommended even though there is limited data supporting these medications for ADHD treatment in adults.


    About the Lecture

    The lecture ADHD Treatment Guidelines: Scoring and Starting Pharmacotherapy by Rhonda Lawes, PhD, RN is from the course ADHD Treatment Guidelines.


    Included Quiz Questions

    1. School and home
    2. School only
    3. Home and playground
    4. Hospital and home
    5. Clinic and school
    1. Blood pressure
    2. Lung function
    3. Liver enzymes
    4. Brain imaging
    5. Bone density
    1. Atomoxetine
    2. Amphetamines
    3. Methylphenidate
    4. Clonidine
    5. Guanfacine

    Author of lecture ADHD Treatment Guidelines: Scoring and Starting Pharmacotherapy

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN


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