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ADHD Flowplan page2

Initial Information synthesis (may be part of


first visit)

no Consider other diagnosis,


Age 4+, significantly impacting home and consider MH referral
school?
yes

Address deficit. ADHD may still


Sleep, vision and hearing are adequate? no
be present or these may be
mimicking
yes

Talk to parent about


concern
No initial concern for learning disability? getting SIT/504/IEP,
support parent in
No concern obtaining school

concern Consider addressing


No major physical exam abnormalities? physical abnormalities,
consider syndrome or
No concern
developmental concerns

No major mental health concern based on concern Refer to MH. Even if


HBHM screening? ADHD is present,
complexity warrants
No concern management by MH
team. Assure pt not
no
Parent Connors suspicious for
Further explore parent beliefs about ADHD,
ADHD?
inquire who informs parent about issues like
Consider yes
this,
awaiting verbally review motivational interviewing
teacher questions in HBHM screening form (e.g. why
Connors Discuss initial potential
not higher or lower),
and rest of for ADHD and need for
provide initial info about behavior mod
packet. rest of data
techniques,
Consider explore feelings about meds, provide initial
another Consider the following 9- info about meds including side effects,
caregiver topic discussion (time answer other questions,
perspectiv permitting) schedule follow up,
e. remind parent to assure other forms are
Consider
ADHD Flowplan page 3 returned,
MH recommend school completes IEP/504
ADHD Diagnostic workup completion (usually
second visit)

CBCL and parent intake May need more information


no
completed, returned and before completing
scored by MH? diagnostic work up. In
limited circumstances
yes treatment might proceed
pending some of this info
but it is not generally
Teacher Connors no
recommended
returned?

yes
Advocate for
completion of this.
Take home documents support diagnosis of
May decide to
ADHD?
continue toward
no yes
treatment

Review behavior 504/IEP no


Consider MH
modification techniques initiated?
referral,
and results
parenting yes
help
yes Behavior modification Home
working? IEP helping? yes behavior
improve
School No or partly No or partly d?
performan
ce

yes no no yes
Consider medication
initiation

Reinforce Review parents feelings about meds Reinforce


and and
enhance Review med benefits and risks
Medication Initiation enhance
Recommend medication

Review prescribing process and follow


up
explore concerns should be 2wks to 1 should be 1 mo later
validate concerns mo later should generally follow
emphasize ability to review initial benefits ADHD follow up form
stop or change med and side effects inquire about
address perceptions, low initial dose brings adherence
misperceptions and higher risk of benefits inquire about sense of
limitations of wearing off midday efficacy
medications inquire about teacher ask about side effects
discuss chosen med feedback from physical, to
prim

and (low) initial dose review ongoing behavioral, to


behavior mod efforts emotional and severe

subsequent followup
discuss potential side
arym

effects remind parent child document school


discuss expected side won't think it is performance across
effects (this will helping several subjects per
the form
edinitiation

demystify and build adjust regimen if

First follow up
some confidence in indicated document quality of
your ability) interactions with
peers, teachers and
parents
review ongoing
behavior mod efforts
mention potential for
misuse as well as
avoidance
If current regimen
seems acceptable
then follow up in 3
months
if current regimen
needs adjusting then
follow up in one month
ADHD medication discussion points

Some points to consider discussing with parents or thinking about when prescribing
ADHD medications. This does not include specific medication recommendations and
dosing guidelines as those are available elsewhere. This is also not an exhaustive
discussion, but tends to be some of the topics covered over the course of the
diagnostic workup and medication initiation visits.

See SCH ADHD medication algorithm for dosing initiation and ongoing treatment
recommendations

Behaviors that wont change


o Comorbidities like Oppositional, Anxiety
o Habits like nail biting, sleeve sucking, cheek chewing, lip smacking
Dispelling myths
o ADHD meds wont make someone more prone to addiction
Expected initial side effects (these should diminish after 2wks consistently on
med)
o Zombie
Hard for parents to see at first; especially if already ambivalent
about meds
Some of this is parent perception; being unused to child sitting
still
Some is actual periods of spaciness (may be sign of dose being
too hight)
o Sleep changes
Often quickly improves if meds are taken daily
Avoid giving meds too late in day to help prevent this
o Late afternoon moodiness
Often child was previously not prone to getting very emotional
about little things
Now suddenly tends to cry over spilled milk or a broken pencil
tip
Most common in 4-6 pm time period
Expected longer term side effects (these may not change in intensity)
o Appetite suppression
Weight loss can be dramatic
Reinforce that a child should eat before taking their medication
Uncommon side effects (should probably prompt you to seek MH consultation
for med management)
o Hallucinations
o Tics
May mean the child was prone to them.
Controversial issues
o Cardiac
Varying recs from varying specialty groups. Now generally not
considered a high risk, but consider cardiology referral before
starting meds if there is a strong family history of non-lifestyle
related cardiac disease or if child has history of fainting with
exertion
Ramping up
o We generally start at low doses to see if meds have prospect for
benefit, to minimize side effects
o May also lead to reports of med wearing off in school in late morning
or afternoon
o Some parents note remarkable improvements right away. Some of
them seem to experience a honeymoon of improvement followed by
many months working with you to find the right medication and dose.
Other parents dont experience much of an improvement at first and
also require several months to get to the best regimen
Single dose v twice daily
o We tend to initiate and stay with once a day longer acting meds
o Some children need shorter acting meds added on for quicker onset at
the start of school or at midday to help in the afternoon
Mixing medications
o Be very cautious of using two different ADHD medications
o A child on other psych meds may be an indication for MH to manage
the ADHD med too
Childs perspective
o Few children will say that the medication is helping them
o They will put up a lot of passive and active resistance which is an
added burden to parents
o If you ask a child if they think their improved school performance is
due to the medication they will probably say no. If you ask them if
they are getting along better with friends they might recognize this is
partly due to the med.
o Occasionally the school is a better place to administer and monitor
morning meds. Especially if the child is receiving breakfast at school
Compliance
o Parents may need to become very vigilant. May need to assure the
child takes the med in their presence
o 1/3 of kids wont respond to first medication favorably. Encourage
parents not to get discouraged
o The return of the short term side effects, like new onset sleep trouble
after theyve presumably been on the medication for months, might be
an indication that child is intermittently not taking meds
o Decrement in school performance after initial improvement,
reemergence of zombiness or crying over spilled milk might also
indicate a compliance problem
Abuse
o High risk for selling/sharing with other students
o One of the most sought after meds for high academic performing youth
o Some kids may hoard and binge, with behavior swings that match
o Good communication with school may be an important factor for both
parent and clinic
Breaks
o Not necessarily a bad thing. Many parents choose to do this during
periods of less expectation
o Warn parents that social events, like parties or camp may actually be
times when the meds are especially necessary
o Remind parents to expect more of the temporary side effects to re-
emerge when meds are stopped and started.
o Some parents plan to hold med on weekends. Pay attention to how
Mondays go in school and with sleep
Long term
o A number of youth are off ADHD meds by later adolescents
Other family members
o A number of parents come to recognize their own ADHD during the
childs work up
Prescribing
o Cannot be phoned in to a pharmacy
o Cannot have refills authorized
o A prescription must be written for each month
o Early on, with medication adjustments, it can be difficult to get
prescriptions filled if youve already written one for that month
o If a child has been on a stable dose for many months and no changes
are expected then some prescribers with good relationships with
parents will write a prescription for a following month and notate with
dont fill until ______