Transcript Learning Session 3 Presentation Slides

PSP Child & Youth Mental Health
Learning Session 3
© 2012 British Columbia Medical Association and Dr. Stanley P. Kutcher. Health educators and health
providers are permitted to use this publication for non-commercial educational purposes only. No part of
this publication may be modified, adapted, used for commercial or non-educational purposes without the
express written consent of the BCMA and Dr. Kutcher.
Presenter’s name here
Location here
Date here
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
2
Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
3
Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
4
Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
5
Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
6
Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
7
$1,540.18
$160.00
Objectives
By the end of this session, you will be able to:
 Use appropriate tools to assess and plan a management strategy for child-andyouth-aged patients with ADHD
 Use appropriate pharmacological treatment for management of children and
youth with ADHD.
 Develop a care plan to address patients with ADHD that utilizes CYMH tools
and resources
 Develop a collaborative working relationship with a CYMH team and other
community providers (school counselors, specialists, community services, etc.)
 Identify appropriate community resources to support child-and-youth-aged
patients with anxiety, depression, and ADHD
8
A mind that is stretched by a new
experience can never go back to its
old dimensions.
-Oliver Wendell Holmes, Jr.
9
10
Child
& Adolescent
Attention Deficit
Hyper Activity
Disorder
(ADHD)
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Fast Facts:
Child & Adolescent ADHD
 Receives much media attention and controversy
 Neuro-developmental psychiatric disorder
 Impairs social, academic, family, and occupational
functioning
 In Canada: 5 – 10 % in youth; 3 – 5 % in adults
 Associated with serious mental disorders:
13
›
Learning Disability
›
Conduct Disorder
›
Oppositional Defiant Disorder
Fast Facts:
Child & Adolescent ADHD
 Greater risk for:
›
Poorer academic achievement
›
Fewer friends
›
Lower self-esteem
›
Teen pregnancies
›
Substance misuse/abuse
›
Interpersonal difficulties
 More prone to:
14
›
Physical injury
›
Accidental poisoning
›
Traffic accidents
www.freedigitalphotos.net Upsidedown Vehicle by Bill Longshaw
Typical School Report Card Notes
 Stanley [Kutcher] is disruptive in class, he is always talking and has
great difficulty sitting still
 Stanley cannot settle down to do desk work – he is always fidgeting
 Stanley is not getting his homework done, he forgets to take his work
home or to bring his homework to school
 Stanley’s grades do not reflect what he is capable of doing
 Stanley is so disorganized that he will never be successful at
anything
15
ADHD Screening Question
3.
Overall, do you have problems
concentrating, keeping your mind on
things or do you forget things easily (to
the point of others noticing and
commenting)?
›
If YES – consider ADHD
›
Apply the SNAP-IV 18 item scale
›
Proceed to the Identification,
Diagnosis and Treatment of the
Child and Adolescent ADHD
Module
16
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ADHD Screening Tool – Youth Version
Are you able to finish most things that you start within the time others expect?
Do you have trouble paying attention to things that are not that interesting to
you?
Do you fidget or feel you have to move around much of the time?
Do you often do things without thinking?
Are you having problems at home or school related to your behaviour or because
of trouble paying attention?
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Have these difficulties been there for a long time (six months or longer)?
www.freedigitalphotos.net Question Or Doubt by Jeroen van Oostrom
ADHD Screening Tool – Parent Version
Does your teenager usually not finish things that he or she starts?
Is your teenager not able to pay attention to things for as long as other
teenagers?
Does your teenager fidget or move around much of the time, even when he/she
knows she should not?
Is your teenager impulsive or does he/she act without thinking much of the
time?
Is your teenager’s behaviour causing him/her problems at home and at school?
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Have these difficulties been there for a long time (six months or longer)?
www.freedigitalphotos.net Family by Master isolated images
Step 1:
Identification of Risk for ADHD
Well established and
significant risk effect
1. A previous diagnosis of
ADHD
2. Family history of ADHD
3. Family history of mental
disorders (affective, anxiety,
tics or conduct disorder)
4. Psychiatric Disorder:
Oppositional Defiant Disorder,
Conduct Disorder or a
Learning Disorder
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Less well established
risk effect
Possible “group”
identifiers
(these are not causal for
ADHD but may identify
factors related
to adolescent onset
ADHD)
1. Exposure to severe
environmental factors (i.e., lead
contamination, prenatal exposure
of alcohol and cigarette, birth
trauma, low birth weight, head
injuries).
2. Psychosocial adversity such as
maternal depression, paternal
criminality, chaotic home
environment, and poverty
3. Substance misuse/abuse (early
onset of use including cigarettes
and alcohol)
4. Head injury (concussion)
1. School failure or learning
difficulties
2. Socially isolated from peers
or behavioural problems at
home and at school
(including gang activity &
legal problems) – accident
prone.
3. Bullying (victim and/or
perpetrator)
Screening & Diagnosis of ADHD
Approx. 65% of children with ADHD still
meet diagnostic criteria during adolescence
 Child/Adolescent may show:
› Inattention
› Distractibility
› Impulsivity
› Hyperactivity
 Requires health provider
intervention
› Differentiate between normal responses to circumstances or developmental
changes in normal children
› Use the “Distress versus Disorder” model
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Screening & Diagnosis of ADHD
3 Sub-categories
21
1.
Predominantly Inattentive
2.
Predominantly Hyperactive-Impulsive
3.
Combined Inattentive/Hyperactive
Clinical Findings for ADHD
Early Childhood 3 – 5 years of age





Difficulty attending to tasks
“Squirmy”
Difficulties “settling”
Very active, always on the go
Parents refer to child as:
› “Not listening”
› “Zippy”
› “Always running around”
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Clinical Findings for ADHD
Middle Childhood 6-12 years of age

Child may not persist long with most tasks
› Particularly what they do not want to do
 Parents report child:
› Does not pay attention or listen
› Is very forgetful or disorganized
 Described as:
› “Overactive”, “always on the go”
& “cannot sit still”,
› Acting out of turn
› Blurting out in class
› More evident in situations where attention is expected
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www.freedigitalphotos.net Girl With Bunny by Teeratas
Clinical Findings for ADHD
Middle Childhood 6-12 years of age
 School reports, “…not living up to academic
potential”
 Difficulty with peers
 Impulsivity & intrusiveness
An active child does not mean ADHD
Girls with ADHD may demonstrate
inattentiveness, not hyperactive symptoms
24
Clinical Findings for ADHD
Adolescence 13 – 19 years of age






Easily distracted from tasks
Feelings of inner restlessness
Stopping short on tasks
Forgetful; fail to complete tasks
Fidgety
Difficulty with relationships
› Many “breakups”
 Impaired temper control
 Impulsive decision making
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Clinical Findings for ADHD
Adolescence 13 – 19 years of age
 Engage in “risky” behavior
› At higher risk for traffic accidents
 Considered “lacking maturity” for their age
 Without treatment, exhibit signs of demoralization
› Due to negative comments
› “Nagging” from parents, teachers, adults and peers
› Do not confuse demoralization with depression
 May get involved in drug use and criminal behavior
 School drop outs, especially with unidentified
learning disability
26
Youth ADHD Screening Q’s
Inquire about substance
misuse/abuse
- Including marijuana Youth with ADHD may be more likely to
use a variety of substances
Specialist consultation
for substance abuse & ADHD
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 Assessment of ADHD
› Four 15 minute office visits
 Treatment is NOT an emergency
› Take your time
› Ensure diagnosis is correct
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Assessment Tool
SNAP-IV
Teacher and Parent 18-item Rating Scale
 A norm-referenced checklist
 DSM-IV criteria for ADHD
29
Assessment Tool
SNAP-IV
Teacher and Parent 18-item Rating Scale
Young person must meet the following criteria:
 Some symptoms present before age 7 years
 Some impairment present in two or more settings
 Clear evidence of clinically significant impairment
30
Assessment Tool
SNAP-IV
Teacher and Parent 18-item Rating Scale
 Rating scale alone not sufficient to diagnose
 For diagnosis and clinical intervention must have:
› Complete history
› Appropriate physical examination
 Ensure DSM-IV-TR criteria is met
31
Assessment Tool
SNAP-IV
Teacher and Parent 18-item Rating Scale
 What to do if a SNAP-IV score of 18 or higher:
32
Monitoring and Intervention Tools: ADHD
Monitoring
 CGI
 TeFA / CFA
 TASR-A
 SNAP-IV
Interventions (these do not replace
medications or psychotherapies)
 PST
 WRP
33
Children
Visit 1
Consider risk factors
Apply screening tool
Complete CFA
Complete SNAP-IV
Visit 2
SNAP-IV 18 item
CFA
Use PST
and WRP
34
If risk factors are substantial or if three or more positives answers on
either the Parent or Child Version of the Screening Tool or CFA suggests
dysfunction due to ADHD like symptoms - Use the Psychotherapeutic
Support for Children (PSC) and Stress Reduction Prescription
(WRP) (proceed to step 2 in 1 - 2 weeks.) Complete SNAP-IV. Provide
SNAP-IV to parents and teachers. Provide information about ADHD and
its treatment. Obtain informed consent to allow discussion with the
school.
If fewer than 3 positive answers on The Parent or Adolescent version of
the Screening Tool - consider other possible explanations for
signs/symptoms such as: environmental stressors, Oppositional Defiant
Disorder, Conduct Disorder, Learning Disorder.
Use the Psychotherapeutic Support for Children (PSC) and Worry
Reduction Prescription (WRP) and monitor again in a month and repeat
STEP I and review other possible psychiatric conditions.
If SNAP-IV 18 > 18 (or a mean score of greater than 1) and CFA shows
decrease in function - continue with PST and WRP strategies - proceed
to step 3 within a week. Review SNAP-IV from parents and teachers for
scores as above. Discuss ADHD and its treatment and encourage
“google search”.
If SNAP-IV 18 <18 (or a mean score of greater than 1) and shows no
decrease in function – continue with PST and WRP strategies and
monitor again in a month – advise to call if feeling worse or problems
escalate.
Children
If SNAP-IV 18 remains > 18 (or a mean score of greater than 1) and CFA
shows functioning problems – proceed to diagnosis (review DSM-IV-TR
criteria) and treatment after discussion of ADHD and treatment options**
Visit 3
SNAP-IV 18
CFA
Use PST
and WRP
If SNAP-IV 18 <18 (or a mean score of greater than 1) and CFA shows no
decrease in function – continue with PST and WRP strategies - monitor
again with SNAP-IV 18 and CFA in one month – advise to call if feeling
worse or problems escalate. Consider Strongest Families BC.
35
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Youth
Visit 1
Consider risk factors
Apply screening tool TeFA
SNAP-IV
Visit 2
SNAP-IV 18 item
TeFA
Use PST
and WRP
36
If risk factors are substantial or if two or more positives answers on
either the Parent or Adolescent Version of the Screening Tool or TeFA
suggests dysfunction due to ADHD like symptoms - Use
Psychotherapeutic Support for Teens (PST) and Worry Reduction
Prescription (WRP) , see page 21 - proceed to step 2 in 1 - 2 weeks
Provide SNAP-IV to parents and teachers (school contact can be
through parents if feasible). Complete SNAP-IV 18. Provide information
about ADHD and its treatment. Obtain informed consent to allow
discussion with the school.
If fewer than 3 positive answers on The Parent or Adolescent version of
the Screening tool - consider other possible explanations for
signs/symptoms such as: environmental stressors, Oppositional Defiant
Disorder, Conduct Disorder, Learning Disorder. Use PST (see page 29)
and WRP (see page 21) and monitor again in a month and repeat STEP I
and review other possible psychiatric conditions.
If SNAP-IV 18 > 18 (or a mean score of greater than 1) and TeFA shows
decrease in function - continue with PST and WRP strategies - proceed
to step 3 within a week. Review SNAP-IV 18 from parents and teachers
for scores as above. Discuss ADHD and its treatment and encourage
“google search”.
If SNAP-IV 18 <18 (or a mean score of greater than 1) and shows no
decrease in function – continue with PST and WRP strategies and
monitor again in a month– advise to call if feeling worse or problems
escalate.
Youth
Visit 3
If SNAP-IV 18 <18 (or a mean score of greater than 1) and TeFA shows no
decrease in function – continue with PST and WRP strategies - monitor
again with SNAP-IV 18 and TeFA in one month – advise to call if suicide
thoughts or acts of self-harm occur or if problems escalate.
freedigitalphotos Sujin Jetkasettakorn
SNAP-IV 18
TeFA
Use PST
and WRP
If SNAP-IV 18 remains > 18 (or a mean score of greater than 1) and TeFA
shows decrease in function – proceed to diagnosis (review DSM-IV-TR
criteria) and treatment.
37
Co-morbidity in ADHD
 Approx. 30 – 50% of people with ADHD
have other psychiatric disorders
› Oppositional Defiant Disorder (ODD)
› Conduct Disorder (CD)
38
› Learning Disorder
Co-morbidity in ADHD
 Begin treatment
 Refer child/youth to specialty services or Stronger
Families
 If learning disability is suspected:
› Refer for educational psychological testing
› Contact school
› Remedial learning strategies
› Informed written consent to contact school
39
www.freedigitalphotos.net by Salvatore Vuono
Pharmacological Treatment of
Child & Adolescent
ADHD
40
Baseline Measurement
CBC







41
Ht
Wt
BP
Pulse
SNAP-IV 18
W
F
I C
R F
S A
\
P
History
KSES-A
Complete blood count (CBC)
Height; Weight; Blood Pressure; Pulse Rate
SNAP-IV 18 Items Rating Scale
WFIRS-P (Weiss Functional Impairment Rating Scale- Parent Report)
CFA (Child Functional Assessment)
KSES-A (Kutcher Side Effects Scale for ADHD Meds)
Family history of heart disease
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Facts About Stimulants
 Do not cause addiction in ADHD treatment




> Tolerance develops occasionally
Decreases rates of future substance abuse
Improves outcomes in functioning
“Drug holidays” are not needed
Long acting, once per day dose easiest
42
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Stimulants & Non-Stimulants
Stimulants
Highly effective
Available for decades
Well studied
Safe prescribed to healthy
patients under medical
supervision
Non-Stimulants
1.
2.
3.
Available in two different forms
Short-Intermediate
Release Preparations
Repeated doses/day
More adverse effects
Stigma associated with
taking at school.
Methylphenidate’s
Ritalin®
Ritalin® SR
PMS or Ratio Methylphenidate
Dextroamphetamine Sulphate’s
Dexedrine
43
For youth…
Not responding well
to stimulant
medications
At risk for substance
abuse
With other
conditions with
ADHD
Extended Release Preparations
Preferred over short-acting
medications, Better compliance;
less diversion.
More expensive, not all Canadian
medication insurance plans cover.
Mixed Salts Amphetamine
*Adderall XR
Methylphenidate
*Biphentin
*Concerta
*Novo-Methylphenidate ER-C
Lisdexamfetamine Dimesylate
*Vyvanse
Atomoxetine
*Strattera
Is the only nonstimulant medication
that is approved to
treat children /
adolescents with
ADHD.
Additional ADHD Medications
 Tricyclic antidepressants (not
> Imipramine or Desipramine
 Bupropion
> Wellbutrin
 Clonidine
recommended)
Reserve these medications
for specialty mental health services
44
www.freedigitalphotos.net by Wishedauan
 Evaluating response to
Methylphenidate
> 3-day baseline assessment
o SNAP-IV 18
 Alternate every 3 days for 12 days:
> Dose of methylphenidate (standard release)
o 5 mg/BID or 10 mg/BID depending on weight
> Dose of placebo
 Daily measurement
> Symptoms (SNAP-IV 18)
> Side Effects (KSES-A)
Day
1
Day
2
No Medication
45
Day
3
Day
4
Day
5
Day
6
510mg
/bid
510mg
/bid
510mg
/bid
Day
7
Day
8
Day
9
Day
10
Day
11
Day
12
Placebo Medication
510mg
/bid
510mg
/bid
510mg
45
/bid
 Concerning with alcohol/drug abuse
> Careful evaluation and monitoring
> Avoiding drug diversion
> Sustained-release preparations
> Non-stimulants
> Consider using Atomoxetine
> Studying for exams
46
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Methylphenidate Treatment
START LOW & GO SLOW
Begin: 2.5mg – 5mg; morning and noon; 30 – 45 minutes before meals.
Maintain for 1 wk.
If insufficient effect, tolerable and no significant side effects increase to 5mg - 10mg in morning and
2.5mg - 5mg at noon and maintain for a week
If needed, increase: to 5 mg – 10mg in the morning and 5mg – 10mg at noon. Maintain for 1 wk.
If insufficient effect, tolerable and no significant side effects increase: to 5 mg – 10mg in the morning,
5mg – 10 mg at noon and 2.5 – 5mg at 4pm. Maintain for 1 wk.
Continue stepped titration by 2.5mg - 5mg weekly to a maximum total daily dose of 2mg/kg/d not to
exceed 60 mg, measuring outcomes every week following the step increase.
After beginning dose and increases:
Measure outcomes using SNAP-IV 18 items
(aiming for a score of less than or equal to 18) and the KSES-A
If Side Effects…
…become a problem, while no substantial improvement, increase time between increases from 1 wk to
2 wks; continue steps.
…limit dose increases to optimize symptom control, refer to specialty services or change to
Dextroamphetamine .
Discontinuation: Taper gradually over several months at low stress
times
47
Dextroamphetamine Treatment
START LOW & GO SLOW
Begin: 2.5 mg – 5mg in the morning and 2.5mg – 5mg at noon; 30 – 45 minutes before meals. Maintain for
1 wk.
If insufficient effect, tolerable and no significant side effects increase to 5 mg - 10mg in morning and 2.5mg
- 5mg at noon and maintain for a week
If insufficient effect, tolerable and no significant side effects increase to 5 mg - 10mg in morning and 5mg 10mg at noon and maintain for a week
If insufficient effect, tolerable and no significant side effects increase: to 5mg - 10mg in the morning and
5mg – 10mg at noon and 2.5mg – 5mg at 4pm. Maintain for 1 wk.
Continue stepped titration by 2.5mg – 5mg weekly to a maximum total daily dose of 20 mg, - 40mg
measuring outcomes every week following the step increase.
After beginning dose and increases:
Measure outcomes using SNAP-IV 18 items
(aiming for a score of less than or equal to 18) and the KSES-A
If Side Effects…
…become a problem, while no substantial improvement, increase time between increases from 1 wk to 2
wks; continue steps.
…limit dose increases to optimize symptom control, refer to specialty services or change to Methylphenidate
if not tried yet or consider Atomoxetine .
Discontinuation: Taper gradually over several months at low stress times
48
Non-Stimulant Atomoxetine Treatment
START LOW & GO SLOW
Begin: 0.5 mg/kg/d in the morning for 2 wks
Increase: to 0.8 mg/kg/d in the morning for 2 wks
Increase: to 1.0 mg/kg/d in the morning for 2 wks
After beginning dose and increases:
Measure outcomes using SNAP-IV 18 items
(aiming for a score of less than or equal to 18) and the KSES-A
If Side Effects…
…become a problem, while no substantial improvement, increase time
between increases to 4 wks
…limit dose increases to optimize symptom control, refer to specialty
services.
…and symptoms are not under optimal control, increase to 1.2mg/kg/d
in the morning; maintain for a period of 2 wks.
Measure outcomes using SNAP-IV 18 items and the KSES-A.
49
Discontinuation: Taper gradually over several months
at low stress times
NOTE:
If symptoms are
not under
optimal control
with 1.2mg after
maintaining it for
at least 6 weeks
refer to
speciality
service.
Switching to Long Acting Forms…
 When total daily dose is determined…
> Switch to long acting form
o Biphentin
o Concerta
o Nova-Methylphenidate ER-C
> Single daily morning dose
 Equivalent of initial Ritalin dose
 Long acting Methylphenidate
> Start at lowest dose; increase weekly
> Essential to evaluate twice/wk
o SNAP-IV
o Side Effects Scale
50
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Switching to Atomoxetine
 If switching for reasons other than side effects
> Add Atomexetine until ADHD symptoms improve
> Then stop Methylphenidate
Use PST Based Supportive Rapport
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Subjective Side Effects
Never
Somewhat
Constant
Anorexia
0
1
2
3
4
Weight Loss
0
1
2
3
4
Abdominal Pain
0
1
2
3
4
Dry Mouth
0
1
2
3
4
Nausea
0
1
2
3
4
Vomiting
0
1
2
3
4
Fearful
0
1
2
3
4
Emotional Lability
0
1
2
3
4
Irritable
0
1
2
3
4
Sadness
0
1
2
3
4
Restlessness
0
1
2
3
4
Headaches
0
1
2
3
4
Trouble Sleeping
0
1
2
3
4
Drowsiness
0
1
2
3
4
Dry Eyes
0
1
2
3
4
Suicidal Ideation
0
1
2
3
4
Rash
0
1
2
3
4
Acne
0
1
2
3
4
Dyskinesia
0
1
2
3
4
Tics
0
1
2
3
4
Other Movements
52
Sexual Effects
0
1
2
3
4
0
1
2
3
4
Kutcher
Side
Effects
Scale
for ADHD
Meds
Monitoring Treatment of
Attention Deficit
Hyper-Activity Disorder
Bas
eline
Day
1*
Day
3*
Wk
1
Wk
2
SNAP-IV
18
x
x
x
x
x
x
x
x
CFA/TeFA
WFIRS
x
x
x
x
x
KSES-A
x
x
x
x
x
Tool
53
x
x
* For Stimulants Only
x
Wk
3
Wk
4
Wk
5
Wk
6
Wk
7
Wk
8
Duration of Treatment
Maintain treatment for defined length of time to:
1. Allow for further improvements in symptoms
2. Allow for additional therapeutic interventions to occur
(e.g. CBT or parent training)
3. Decrease risk of relapse
4. Decrease risk of a
co-morbid mental disorder
54
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Sustaining Your Gains
55
You can all work as one to sustain changes in
practice and community!
56
Thank you!
57