By: Jenna Schmidt
Attention Deficit Hyperactivity
Disorder
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ADHD is caused by a chemical imbalance in the brain
that affects the parts controlling attention, concentration
and impulsivity. This means a child’s behavior can be
anything from being ‘very dreamy’ (or unable to pay
attention) through to being ‘always on the go’ (or
hyperactive).
A person with ADHD has difficulty filtering out all the
information coming into his brain, so he’s easily
distracted, tends to respond before he has considered
things properly and doesn’t know when to stop.
A child with ADHD will take longer to settle and
concentrate than a child without, and may have
problems following instructions.
ADHD Continued…
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Children with ADHD often have above-average
intelligence but find it hard to learn. They often also
have problems socializing.
The condition is long term and can continue through
adult life. There is a genetic component, and children
with ADHD often have relatives (frequently male) with
ADHD.
It isn’t caused by bad parenting, but a child’s
surroundings and support can affect how severe the
symptoms are and how well he can learn to deal with
them.
Past Names For ADHD
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ADHD was first described by George Still in 1902. He called it
‘morbid defect of moral control’. It’s also been called:
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minimal brain damage (1930).
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minimal brain dysfunction (1960).
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hyperkinetic reaction of childhood (1968).
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attention deficit disorder (ADD) with or without hyperactivity (1980).
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Since 1987, it has been known as ADHD or attention deficit
hyperactivity disorder. The World Health Organization brought out a
second definition in 1992, ‘hyperkinetic disorder’, a narrower
definition than ADHD and comprises only the more serious cases.
DSM IV TR- 3 types
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ADHD combined type: this is the most common type,
and means the child has six or more symptoms in each
category.
ADHD predominantly inattentive type: this means
the child has six or more inattention symptoms but fewer
than six hyperactivity-impulsivity symptoms.
ADHD predominantly hyperactive-impulsive type:
this is the least common type and means that the child
has six or more hyperactivity-impulsivity symptoms but
fewer than six inattention symptoms
Symptoms of ADHD
Inattention Type:
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(a) often fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play
activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to
oppositional behaviour or failure to understand instructions)
(e) often has difficulty organising tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (such as schoolwork or
homework).
(g) often loses things necessary for tasks or activities (e.g. toys,
school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
6 (or more) of the following symptoms of hyperactivity-impulsivity
have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level
Symptoms of ADHD
Hyperactivity Type:
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(a) often fidgets with hands or feet or squirms in
seat
(b) often leaves seat in classroom or in other
situations in which remaining seated is expected
(c) often runs about or climbs excessively in
situations in which it is inappropriate (in
adolescents or adults, may be limited to
subjective feelings of restlessness)
(d) often has difficulty playing or engaging in
leisure activities quietly
(e) is often "on the go" or often acts as if "driven
by a motor"
(f) often talks excessively
Symptoms of ADHD
Impulsivity Type:
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(g) often blurts out answers before questions have been
completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g. butts into
conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms
that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or
more settings (e.g. at school [or work] and at home).
D. There must be clear evidence of clinically significant
impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course
of a Pervasive Developmental Disorder, Schizophrenia, or
other Psychotic Disorder and are not better accounted for
by another mental disorder (e.g. Mood Disorder, Anxiety
Disorder, Dissociative Disorder, or a Personality Disorder)
Population
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According to the National Institute of Mental
Health two to three percent of children have
ADHD. This means that in a typical classroom at
least one child is ADHD. The NIMH estimates
that about 2 million children in the United States
have ADHD.
A neurologist by the name Dr. Fred Baughman
estimated that 500,000 children were diagnosed
with ADHD in 1985 and he estimates that there
are now 5 to 7 million children with this
diagnosis.
Treatment Options
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medication
behavioral therapy
psychotherapy
educational techniques.
The most effective way to treat ADHD is a
combination of these options.
Medication Treatment
Some Psychostimulants Include:
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Methylphenidate (Ritalin, Concerta)
Dextroamphetamine/amphetamine (Adderall)
Dextroamphetamine (Dexedrine)
Atomoxetine (Strattera) – a non-stimulant with similar
effective action is also used.
Other Non-Stimulant Medications Include:
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imipramine and bupropion (Brand name: Wellbutrin)
(both antidepressants)
clonidine, which may help children with ADHD who have
aggressive antisocial behavior.
Behavioral Therapy Treatment
teachers and parents learn strategies such
as:
• CBT- contingency management procedures
to deal with children’s behavior. The
strategy includes:
• token reward system
• timeouts.
Psychotherapy Treatment
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Older children and adults suffering from
ADHD are allowed to talk and discuss the
issues that trouble them, explore negative
behavioral patterns and permitted to learn
the ways to deal with their symptoms.
Educational Techniques
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Support Groups- These groups offer a net work
of social support, information and education to
adults and children suffering from ADHD and
their parents, friends and relatives.
Social Skills Training- This helps children to learn
appropriate social behavior.
Parent Skills Training- This helps the parents to
develop ways to understand and guide the child
in his day-to-day life. Best results are be
obtained with teachers, parents and therapists
or physicians working in teams.
Present Research
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Virtual Reality Study for Young males ages
12–16 (Fitzgerald)
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Genetics of ADHD (Kollins)
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Follow-up of the Multimodel Treatment
Study of ADHD Children (MTA) (Murray/Wells)
The MTA Study
ADHD Researchers
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Russell Barkley, PhD,
Rutter, M. & Smith, D. (1995)
Kewely, G. (1998)
Hinshaw, S. (1994)
Hill, P., & Cameron, M. (1999)
Farrington, D. (1990)
Cooper, P. (1997)
Angold, A., Costello, E., & Erkanli, A. (1999).
Assessment Instruments
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The most important diagnostic tool is the clinical interview.
A thorough medical examination is important to identify other
conditions that may be responsible for symptoms that coexist
with ADHD and require treatment.
Various psychological tests are used to diagnose ADHD; The
Conners' Parent and Teacher Rating Scale (for children) and
the Brown Attention Deficit Disorder Scale (BADDS) for teens
and adults are useful tools for diagnosis of ADHD.
Impulsivity and inattention are assessed with the Conners
Continuous Performance Test (CPT), the Integrated Visual and
Auditory (IVA) CPT, or both. The Nadeau/Quinn/Littman
ADHD Self-Rating Scale for Girls is a part of the assessment
for all girls (3).
Outcomes
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Several studies have followed children with ADHD/ADD
into adulthood. Although these results vary from study to
study, it appears that about 50% continue to show
evidence of the disorder in adulthood, especially
attention problems and impulsivity. Almost a third will
have dropped out of high school, and only 5% complete
a university degree compared to 40% of their peers.
Approximately 25% have developed chronic patterns of
anti-social behavior. Clearly, for many children with
ADHD/ADD, this disorder is a chronic condition that can
adversely affect their development over many, many
years. (National Institute of Mental Health)
Evidence Based Practice
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The National Institute for Mental Health concluded that
“long-term combination treatments and the medicationmanagement alone were superior to intensive behavioral
treatment and routine community treatment. And in
some areas—anxiety, academic performance,
oppositionality, parent-child relations, and social skills—
the combined treatment was usually superior. Another
advantage of combined treatment was that children
could be successfully treated with lower doses of
medicine, compared with the medication-only
group”. Most professionals agree that this intervention
should be available to all parents of kids with ADHD.
Evidence Based Practice Cont…
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The NIMH found that the combined
treatment (medication management with
behavior therapy), compared with
medication alone, offered improved scores
on academic measures, measures of
conduct, and some specific ADHD
symptoms
Prior Authorization
Criteria:
 Dose not to exceed 1.5 times the FDA approved maximum.
 No concurrent use of multiple products from this category, ie,
Strattera + Stimulant, Methylphenidate + Amphetamine
 Prior authorization is required for all stimulants for adults age 21
and older.
 Gaining prior authorization for prescription medication requires
phones calls, faxes and request forms, which often can be timeconsuming. Fortunately for both providers and patients, help is on
the way to streamline and accelerate this process.
 Prior authorization requires physicians to show the medical necessity
for a patient to receive a particular medication.
EBP & PA Websites / forms
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Evidence Based Practice:
http://www.cde.state.co.us/cdesped/download/pdf/FF-ADHD.pdf
Prior Authorization Forms:
www.okhca.org
https://www.navitus.com/Prior%20Authorization%20Forms/ADHD%20Stim
ulants%20-%20Arizona.pdf
http://www.dhhs.state.nh.us/NR/rdonlyres/e2emyzsepqvzbgjakmvxdxtm5l6
zsw2b6qfjzcuzujpyjffyew2f3cqsi77f2ywlhnx2i4pnrsyfo3voo3injrlhvnc/CNSAD
HD+5-1.pdf
https://tnm.rxportal.sxc.com/rxclaim/TNM/TC%20PA%20Request%20Form
%20(Provigil).pdf
Organizations & Websites
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Children and Adults with Attention-Deficit/Hyperactivity
Disorder (CHADD)
Phone: (800) 233-4050
http://chadd.org
Attention Deficit Disorder Association (ADDA)
Phone: (856) 439-9099
http://www.add.org/
American Psychiatric Association
Phone: (888) 357-7924
http://www.psych.org/
American Psychological Association
Phone: (800) 374-2721
http://www.apa.org/
Resources
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U.S. Department of Education. (2003). Identifying and Colorado Advisory Network
implementing educational practices supported by (303) 721-0648
rigorous evidence: A user friendly guide. Email: canindiv@aol.com
Washington, D.C.:
Web: www.localsonsors.com/denver/can
Promising Practices Network:
http://www.promisingpractices.net/ Center for Attention Deficit
5835 Lehman Drive
What Works Clearinghouse: http://www.w-w-c.org/ Colorado Springs, CO 80918
(719) 531-9211
Children and Adults with Attention Disorders (CHADD)
499 N.W. 70 Ave. Suite 101 National Information Center for Children
Plantation, FL 33317 and Youth with Disabilities
(800) 233-4050 Rocky MT. CHADD (303) 761-5024 P.O. Box 1492
Web: www.chadd.org Washington, DC 20013
(800) 695-0285 (202) 884-8200
Parent Education and Assistance for Kids (PEAK) Email: mail@aed.org
611 N. Weber, Suite 200 Web: www.nichcy.org
Colorado Springs, CO 80903
(800) 284-0251 (719) 531-9400 National Attention Deficit Disorder Assoc.
Web: www.peakparent.org 1788 Second Street, Suite 200 Highland Park, IL 60035
Parent to Parent of Colorado 847-423-ADDA
2200 S. Jasmine Street Email: mail@add.org
Denver, CO 80222 Web: www.add.org
(877) 472-7201 (toll free) (719) 336-2389
Resources Continued…
Books:
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Brown, T.E. (Ed.) (2000). Attention-Deficit Disorders
and Comorbidities in Children, Adolescents, and
Adults. Washington, DC: American Psychiatric Press.
Goldstein, S., & Teeter Ellison, A. (Eds.) (2002).
Clinician's guide to adult AD/HD: Assessment and
intervention. New York: Academic Press.
Murphy, K.R., & Gordon, M. (1998). Assessment of
adults with AD/HD. In Barkley, R. (Ed.) AttentionDeficit Hyperactivity Disorder: A handbook for diagnosis
and treatment. (pp. 345-369). New York: Guilford Press.
Discussing Diagnosis with Family
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Medications, including side effects of treatment and side
effects of no treatment along with dosage
Other interesting facts:
 60-80% of children with ADHD continue to have
symptoms in adolescence
 4-12% of school age children are thought to have ADHD
 Stimulants can cause unpredictable effects on motor tics,
which transiently occur in 15-30% of children taking
stimulants, but the 'presence of tics before or during
medical management of ADHD is not an absolute
contradindication to the use of stimulant medications.'
Other Information to discuss with
Parents:
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Stimulants include different formulations of methylphenidate:
short acting, such as Ritalin and Focalin, with a duration of 3-5
hours
intermediate acting, such as Ritalin SR, Metadate ER, and Methylin
ER, with a duration of 3-8 hours
long acting, such as Concerta, Rilatin LA and Metadate CD, with a
duration of 8-12 hours and which can be used just once a day
The other type of stimulant includes different formulations of
amphetamine:
short acting, such as Dexedrine and Dextrostat, with a duration of
4-6 hours intermediate acting, such as Adderall and Dexedrine
spansule, with a duration of 6-8 hours
long acting, such as Adderall-XR
References
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Anastopoulos, A. (1999). ADHD. In child and adolescent psychological disorders: A
comprehensive textbook. Oxford: Oxford University Press.
Angold, A., Costello, E., & Erkanli, A. (1999). Cormorbidity. Journal of Child Psychology and
Psychiatry, 40(1), 57-88.
American Psychiatric Association (APA) (1994). Diagnostic and statistical manual of mental
disorders (4th ed). Washington, DC: APA Press.
Barkley, R. (1990). ADHD: A handbook for diagnosis and treatment. New York: Guliford Press.
Cooper, P. (1997). The reality and hyperreality of adhd: an educational and cultural analysis. The
Association of Workers for Children with Emotional and Behavioral Difficulties: East Sutton: South
London Press.
Farrington, D. (1990). Implications of criminal career research for the prevention of offending.
The Journal of Adolescence, 13, 93-113.
Hill, P., & Cameron, M. (1999). Recognizing hyperactivity: A guide for the cautious clinician. Child
Psychology and Psychiatry Review, 4(2), 50-60.
Hinshaw, S. (1994). Attention deficits and hyperactivity in children. New York: Sage Press.
Kewely, G. (1998). Medical Aspects of Assessment and Treatment of Children with ADHD. In
ADHD: Educational, medical and cultural issues, Cooper, P., Ideus, K. (eds). Association of
Workers for Children with EBD. East Sutton: South London Press.
Levy, F. & Hay, D. (2001). Attention, genes and adhd. Hove: Brunner-Routledge Press.
National Institute of Clinical Excellence (NICE) 2000. Guidance on the use of methylphenidate for
adhd. London: NICE Press.
Palmer, E., & Finger, S. (2001). An early description of ADHD: Dr. Alexander Crichton and mental
restlessness. Child Psychology and Psychiatry Review, 6(2), 66-73.
Rutter, M. & Smith, D. (1995). Psychosocial disorders in young people. Chichester: Wiley Press.
Tannock, R. (1998). ADHD: Advances in cognitive, neurobiological and genetic research. Journal
of Child Psychology and Psychiatry, 39(1), 65-99.
Thompson, R. (1993). The brain: A neuroscience primer. New York: Freeman Press.
Weiss, G. & Hectman, L. (1993). Hyperactive children grown up. New York: Guliford Press.