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ADHD Flashcards

1
Q

What are some sources of school failure?

A
  • Health issues
  • Emotional issues
  • Learning issues
  • Attention issues
  • try to distinguish where coming from – cognitive ability specific to subject? auditory or visual? Emotional changes? Etc.
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2
Q

What are the risks to untreated adhd?

A

cascade of negative consequences: poor self esteem –> poor academic performance –> risk taking, substance abuse, etc. –> poor employment options, poor health outcomes, poor relationships

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3
Q

3 characteristicsof adhd

A
  • inattentiveness
  • hyperactivity
  • impulsivity
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4
Q

Definition / diagnostic criteriaADHD

A

Interferes w/functioning across settings: home, school, work

  • Behaviors > signifcant than peers
  • Triad of behaviors beyond range of accepted for “normal”
  • At least 6 months
  • Symptoms before 12 years of age
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5
Q

Neurobiology: structural differences associated w/adhd

A

Chronic neurobehavioral disordersmaller frontal lobes

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6
Q

Neurobiology: functional differences associated w/adhd

A

•Lower blood flow•Response to meds

* Alteration of neurochemical transmissionChronic neurobehavioral disorder

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7
Q

ADHD: genetics vs environment

A

•Very high incidence in twin studies•75% variance in phenotype is genetic, not environmental

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8
Q

Specific genes associated with adhd

A

•Dopamine receptor gene–Cognition, memory, exploratory behaviors•Dopamine transport gene–Site of action of stimulants•Similar genes linked to other mental health issues

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9
Q

prenatal/parinatal factors associated with adhd

A
  • Pregnancy complications
  • Prematurity/SGA
  • Hypoxemia
  • Hypoperfusion:– low cerebral blood flow associated with increased dopamine receptor availability in adols with ADHD
  • Maternal smoking
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10
Q

psychosocial factors associated with adhd

A
  • Maternal depression

* parenting skills/stress

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11
Q

biologicfactors associated with adhd

A
  • Lead exposure: even low lead levels showed hyperactivity in preschoolers
  • Iron deficiency
  • Obstructive sleep apnea
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12
Q

dietfactors associated with adhd

A
  • food additives
  • sugar
  • may be triggers in genetically susceptible child - make better or worse
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13
Q

prevalence of adhd in u.s.

A

~11%

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14
Q

Preschool age: prevalence, type, male vs femaleadhd

A
  • Prevalence: 2-5%
  • Type: 48% hyperactive/impulsive
  • 1:1 female to male
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15
Q

School age: prevalence, type, male vs femaleadhd

A
  • Prevalence: 3-11%
  • Type: many combined, many inattentive/impulsive
  • 1:4 female to male
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16
Q

High School age: type,diagnosisadhd

A
  • Type: more inattentive, esp girls

* Diagnosis: ?? other DOs- ODD, CD, “adolescence”, also difficulty w/APA criteria (before 12y)

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17
Q

Characteristics of inattentiveness in ADHD

A
  • Easily distracted
  • Poor listening skills
  • Poor attention to details
  • Forgetful
  • Disorganized
  • Poor sustained attention to play or tasks
  • Fewer activities requiring sustained attention
  • Loses items
  • Needs redirection
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18
Q

Characteristics of hyperactivity in ADHD

A

Most troublesome for preschoolers/early school age

  • “On the go”, “Driven by a motor”
  • Driven to interact with the environment (restlessness in adolescents)
  • Unable to remain seated, even briefly
  • Difficulty settling to play
  • Fidgety
  • Excessive talking
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19
Q

Characteristics of impulsivity in ADHD

A 
Takes risks
Disregards physical boundaries
Unable to cooperate with peers or adults
Interrupts
Difficulty waiting turns
Unable to delay gratification, even briefly
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20
Q

Characteristics of preschoolers w/ADHD

A
  • Lack of rhythmicity
  • Poor adaptability
  • Sleep disturbances
  • Moodiness/irritability
  • Demanding of attention
  • Slower language development
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21
Q

Preschoolers: behavioral risks associated w/adhd

A
  • Poor impulse control
  • Expelled from preschool settings
  • More disruptive
  • Less cooperative
  • Less opportunity to develop social skills
  • Increased risk of injury
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22
Q

Preschoolers: Social risks associated w/adhd

A
  • Problematic parent/child relationship
  • Family stress
  • Limited activities /experiences
  • Focus on discipline
  • Poor social skill development
  • 89% - significant impairment in at least one relationship
    Intrusive, in your face, no boundaries, first in line, taking turns, sharing
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23
Q

Preschoolers: academic risks associated w/adhd

A
  • Poor pre-academic skill development
  • Delayed emergent literacy
  • Parents don’t extend and expand language
  • Disrupted phonological awareness
  • Lower scores
  • Working memory
  • Planning
  • Cognitive flexibility
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24
Q

Preschoolers: comorbidities associated w/adhd

A
  • 35-50% Oppositional Defiant Disorder
  • 15% Anxiety
  • 13% Depression
  • 19% >1 comorbidity
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25
Q

Challenges to diagnosing adhd in preschoolers

A

high energy level:may be nl

  • non-compliant behavior
  • day-to-day variability in behavior
  • situational response to environment
  • Neurologic immaturity
  • Child-environment mismatch
    Adult expectations of behavior:may be unrealistic for age

Co-morbidity:e.g., dvptl problems

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26
Q

General Characteristics of adhd in school-age children

A

Issues with peers

  • Emotionally immature
  • Prefer younger children or adults
  • Emotional lability
  • Procrastination
  • Disorganization
  • Distractibility
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27
Q

Characteristics of adhd in EARLY school-age childrenboys vs girls

A

Boys: high activity levelGirls: “good”, no trouble

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28
Q

Characteristics of adhd in LATER school-age childrenboys vs girls

A

Boys: increasing oppositional behaviorGirls: more social, talkative

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29
Q

risks forschool-age child with adhd

A
  • Family stress
  • Family relationships
  • Social issues
  • Academics
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30
Q

challenges in diagnosis of adhd in school age children

A
  • Normal development
  • Learning disabilities
  • Medical issues
  • Comorbidities
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31
Q

Course of adhd in adolescents

A

Previously

  • Maturational lag
  • Outgrown in adolescence

Currently

  • 65% persist with symptoms at least into adolescence, often adulthood
  • Some not diagnosed until adolescence
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32
Q

Characteristics of adhd in adolescents

A
  • Hyperactivity declines
  • Inattentiveness more obvious
    School struggles
  • Multiple teachers
  • Multiple expectations

Cognitive demands increase

  • Memory
  • Higher level thinking
  • Independence expected
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33
Q

Comorbidities associated withadhd in adolescents

A

ODD, anxiety, depression, substance abuse DO, personality DO, learning disabilities**

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34
Q

Characteristics suggestive of ODD or conduct DO in adolescents

A
  • Argumentative
  • Negative
  • Easily frustrated
  • Conflicts at school
  • School refusal
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35
Q

Characteristics suggestive of anxiety in adolescents

A
  • Restlessness
  • Difficulty concentrating
  • Irritability
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36
Q

Characteristics suggestive of depression in adolescents

A
  • Social isolation
  • Irritability
  • Boredom
  • Reckless behavior
  • Academic underachievement
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37
Q

Principles of assessment of adhd

A
  • Multiple sources
  • Good tools
  • Recurring themes
  • Connections to school and life outside of school
  • Profile of strengths and weaknesses
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38
Q

Components of ADHD assessment: History

A

History
Past medical

  • Birth
  • Chronic illness
  • Acute illness
  • Trauma
  • Development

Social history

  • Family stressors
  • Out-of-home care
  • Family structure

Family Medical

  • Genetics
  • Sibs, cousins
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39
Q

Components of ADHD assessment: PE

A
  • Affect/emotional response
  • Dysmorphic features
  • Behavior
  • Communication skill
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40
Q

Components of ADHD assessment: Medical Screenings (as indicated)

A
  • Sensory
  • Lead
  • Iron
  • Thyroid
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41
Q

Components of ADHD assessment: Developmental / neurodevelopmental screening

A
  • Language/linguistics
  • Memory
  • Personal-social
  • Motor
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42
Q

Why are parent interviews important in adhd?

A
  • Home less structured
    Different expectations
  • Appropriate
  • Inappropriate

Unaware of full range of behaviors

  • School behavior
  • Social interactions
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43
Q

What to look for in interview w/preschool teacher: adhd

A
  • Normative perspective

* Structured and unstructured samples of behavior

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44
Q

Important concepts w/elementary/HSteacher interview: adhd

A
  • May have no knowledge of outside classroom behavior
  • poor interrater reliability amongteachers
  • Parent-teacher agreement =74%
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45
Q

Characteristics of students perspectives on adhd symptoms

A
  • Under report symptoms

* Under rate level of impairment

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46
Q

Who should be involved in adolescent interviews for adhd and why?

A
  1. Adolescent alone
    * Confidentiality
    * Concerns
  • Perception of school and family issues
    Sensitive topics
  • Use of ETOH, drugs
  • Driving habits
    2. Parents alone
  • Perceptions of issues
  • Contact with school
  • Approaches tried
  • Expectations from evaluation
    3. Adolescent and parents together
  • Shared concerns?
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47
Q

Rating scales in adhd: why, disadvantes, types

A

Attempt to objectify behavior
Some normed to age and gender
Impressionistic, subjective
Some specific to ADHD, others to range of emotional/behavioral problems

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48
Q

Specific provider rating tools for adhd, recommended

A

Vanderbilt (AAP)

  • ADHD
  • Comorbidities
  • Connors
  • McCarney (ADDES) short / long forms
  • Brown ADD Diagnostic Form for Adolescents – Revised
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49
Q

Self-assessment tools for adhd

A

Pediatric Symptom Checklist
ANSER Self-Report ( >9 years)
Brown ADD Scales for Adolescents
Conners-Wells Adolescent Self Report Scale

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50
Q

other adhd assessment tools

A
  • Early Childhood Inventory IV
  • SNAP-IV
  • Child Behavior Checklist
  • Preschool Age Psychiatric Assessment
  • Behavior Assessment System for Children
  • ANSER system
51
Q

academic information used to assess adhd mgmt

A
  • Report cards
  • School progress- teachers’ comments
  • Standardized testing
  • Psychoeducational testing
  • Neuropsychological testing
52
Q

Differentials to adhd for preschoolers: medical

A
  • Normal exuberance
    Medical disorders
  • Seizures
  • Significant lead poisoning
  • Sensory deficit
  • OSA
  • Iron deficiency
  • Chronic OM
53
Q

Differentials to adhd for preschoolers: developmental DOs

A
  • Language delay
  • Fragile X syndrome
  • Intellectual disability
  • Autism spectrum
  • FAS
54
Q

Differentials to adhd for preschoolers: psychiatric DOs

A
  • Depression
  • Anxiety
  • ODD
55
Q

Differentials to ADHD for school age and adolescents

A

Learning disability

  • Mental health issues
  • Chronic conditions
    Sensory deficit
  • Parental expectations
56
Q

What are the components of learning, according to PRK’s slides?

A

Attention

  • mental energy controls
  • processing controls
  • production controls

Temporal - sequential ordering
Spatial ordering

Memory

  • short term
  • active working
  • long term
Language
receptive
expressive
written 
Neuromotor functions
gross motor
fine motor
Social CognitionHigher order cognitionLevine, M, A Mind at a Time
57
Q

Components of a student profile of a child w/adhd

A

Strengths

  • What works best?
  • Affective resources
  • Coping styles

Needs

  • Where does the breakdown happen?
  • What makes it better?
  • Environmental influences
  • How can school facilitate success?
  • Affinities
  • Motivators
58
Q

3 subtypes of adhd

A
  • Inattentive
  • Hyperactive/impulsive
  • combined
59
Q

What are the goals of adhd mgmt?

A

Develop self-regulatory behaviors:

  • maintain self esteem
  • develop social skills
  • foster learning behaviors
  • improve family functioning
60
Q

General mgmt guidelines

A

Chronic condition

  • Long term management
  • Ongoing evaluation of treatment options
  • Careful planning
  • Support for child, caregivers, teachers

Identification of target outcomes

61
Q

mgmt of adhd: education of parents, dhild, adolescent

A

Demystify

  • Chronic condition
  • Symptoms manageable
  • Outcomes good

Destigmatize

  • Not associated with intelligence
  • Not associated with being “bad kid”
62
Q

Environmental mgmt of adhd

A
  • Safe, appropriate boundaries
  • Sense of order and control
  • Consistent expectations/routines
  • Active involvement
  • Collaboration and cooperation
  • Reduced stimuli – TV, music, and computer, phones
63
Q

behavioral mgmt training for adhd: goals

A

Goals

  • Decrease core symptoms
  • Improve parent-child interaction
  • Improve peer interaction
  • Decrease oppositional behaviors
  • Generalize to other settings
  • Much research about use with preschoolers
    difficult for disorganized families to implementFocus on immediate issues
64
Q

Components of behavior mgmt for adhd

A
  • Positive reinforcement
  • Token system
  • Time out
    Response contingency:withdrawal of attn
  • Limit setting
  • Appropriate commands and reprimands
  • Group social skills
  • Cognitive/ behavioral self control training
  • Anger management
  • “report card”
  • Overcorrection
  • Minimize negative feedback
65
Q

Considerations when initiating pharm mgmt

A
  • Seldom should be only treatment but often is only treatment
  • Consider co-morbid conditions
  • Informed consent/assent of adolescents
  • Risk/benefits
66
Q

Monitoring pharm mgmt of adhd

A
  • Side effects: occurrence, monitoring
  • Toxicity: abuse, cardiac, liver
  • Periodic assessment
67
Q

What is the most commonly used category of medications for adhd?

A

stimulants (1.5 million)

68
Q

What is the most successful category of medication used for adhd?

A

stimulants: 80% will improve

69
Q

What areas do stimulants improve in adhd?

A

concentration (mental energy, focus and processing controls)

behavior (decreased impulsiveness)

socialization (reduced activity and intrusiveness)

70
Q

MOA of stimulants for adhd

A
  • Enhance neurotransmitter in brain pathways involved in inhibition
  • Activate brain stem arousal
71
Q

How to dose stimulants

A

until effectiveness w/o side effects

72
Q

What are the categories of stimulants?

A

methylphenidates, amphetamines

73
Q

Methylphenidates used for adhd

A

Ritalin ( S & L):capsule you can empty

  • Focalin ( S & L): isomer of ritalin (5mg=10mg of ritalin)
  • Methylin ( S & L )
    Metadate ( S & L):capsule you can empty

Concerta ( L): must be swallowed whole

  • Daytrana – patch (L)
    Quillivant XR 25mg/5ml(L):liquid
74
Q

What is unique about Daytrana?

A

Apply 2 hours before needed on alternating hips(can be annoying)

  • Remove in 9 hrs.
  • Prior use of stimulants recommended
  • Same safety/ risk profile as oral
75
Q

Stimulant that has less abuse potential

A

Vyvanse - needs to get into stomach to work, less abuse potential

76
Q

Which stimulant is good for afternoon overactivity?

A

Methadate

77
Q

amphetamines used for adhd

A
  • Dexedrine (S & L)
  • Adderall ( S & L)
  • Vyvanse ( L)
78
Q

Characteristics of short-acting stimulants

A
79
Q

Characteristics of long-acting stimulants

A

E.g., concerta is good for older students - steady period of action, ~12h duration

80
Q

What is the newest stimulant and how is it dosed?

A
  • Quillivant 25/5ml
  • Liquid
  • Long acting
  • Start at 20mg ?!
  • Same safety and SE profile as others
81
Q

Potential side effects of stimulants

A

•Appetite suppression•Weight loss•Headaches•Increased heart rate•Increased blood pressure•Tics•Delayed sleep onset•Rebound phenomenon•Growth suppression ?unclear data•Moodiness•Sadness•Lowering of seizure threshold

82
Q

How to manage appetite suppression/wt loss on stimulants

A

eat breakfast before medicationIf on ER, will happen around lunch. They can have snacks before school.amphetamines seem to have more appetite suppression

83
Q

What are some cautions with stimulants

A
  • Significant anxiety, tension, agitation
  • Allergies to components
  • Glaucoma
  • Current or recent use of MAOI
  • Motion or verbal tics or family history
  • Structural cardiac defects
  • Abuse potential
84
Q

Is routine cardiovascular monitoring needed before starting stimulants?

A

Previously it wasin 2008, AAP recommended no ECG: no increased risk of SCD and questionable S/S of ECG in predicting SCD

85
Q

When should CV monitoring be done before starting on stimulants?

A

+ FMH or + personal history of cardiomyopathy, WPW, arrhythmia, long QT, other functional, structural heart issues**Also screen adopted kids who don’t know family Hx

86
Q

What CV history do you need before starting stimulants?

A
  • Careful evaluation before starting stimulants
  • Child’s history
    Family medical history
  • Early events
  • Cardiomyopathy
  • Long QT syndrome
87
Q

What CV f/u is needed on stimulants?

A
  • Vital signs

* Symptoms referable to CV system- syncope, palpitations ( butterfly in my chest), SOB, “heart pain”

88
Q

State of the evidence on medicating preschoolers for ADHD

A

Previous studies in preschoolers

  • Few
  • Short duration

Increase in off-label use of stimulants (3-fold increase during 90s)

  • Many medications not approved for
  • Few long term outcomes or safety data
  • Newer study: Pre-school adhd treatment study (pats)
89
Q

What is PATS?

A
  • Pre-school adhd treatment study (pats):
  • a multi-site randoized control trial (3-5.5yrs)
  • Components: parent training, medication trial
  • Results: parent training alone not helpful, 85% with good response to methylphenidate
90
Q

When are adhd medications recommended for preschoolers, and which ones, accordingto aap?

A
  • IF careful assessment and severe symptoms
  • Use methylphenidate
  • start low, titrate up to effectiveness w/o SEs (tmg)
  • Use short acting throughout day (TID)
91
Q

Impact of stimulants on developing brain, preschoolers

A

no long term safety / efficacy impact

92
Q

SEs of stimulants on preschoolers?

A
  • Question of growth suppression
  • Crabbiness, irritability, fatigue – diminished over time
  • Worry and anxiety -persisted over time
  • Sleep and appetite issues- persisted over time
93
Q

Are dependence and abuse issues when prescribing stimulants?

A

•Dependence–Abused at high doses–Possibly psychological•Abuse•Marketable•SAD: Conflicting reports–Well managed students, less SAD–Potential in non-prescribed students for SAD

94
Q

Concerns with energy drinks and stimulants?

A

Synergy!

95
Q

When might you Rx strattera?

A

Not responding to stimulants or high abuse potential–Mood stabilizing effect if comorbidity

96
Q

What is Strattera?

A

–First non-stimulant for ADHD–Norepinephrine reuptake inhibitor

97
Q

When should effects of Strattera be seen?

A

–2-6 weeks before effects seen–24 hour period of action

98
Q

SEs of Strattera

A

–GI upset –•High protein foods•Start low dose (.5mg/kg)titrate upwards (1.2mg/kg)–Liver toxicity•Dark urine•Itchy skin•Jaundice•RUQ pain

99
Q

When is Intuniv recommended?

A

Non-stimulant! Good for high activity levels, issues w/stimulantsRecommended:

  • Core ADHD symptoms plus irritability, temper regulation
  • Intolerant of stim, tics or sleep issues
  • 6-17 year olds
100
Q

Is Intuniv approved for use w/stimulants?

A

yes!

101
Q

How should Intuniv be taken?

A

1,2,3 and 4 mg tablet qd

  • Swallow only
  • No fatty foods
  • Effectiveness ~2-3 weeks
  • Taper by 1 mg q 3-7 days
102
Q

Intuniv MOA

A

Interacts with receptors in prefrontal cortexguanfacine - a BP medCentral alpha-2 adrenergic agonist

103
Q

Side effects of Intuniv

A
  • Fatigue, drowsiness
    Lowers blood pressure:
  • Lightheadedness, syncope
  • GI: Nausea, stomach pain, constipation, appetite, dry mouth
  • Neuro: Irritability, headaches
104
Q

Monitoring of Intuniv

A

BP and HR @beginning and with every ↑ and then q med check

105
Q

What is the newest non stimulant for adhd?

A

Kapvay / Clonadine

106
Q

MOA of Clonadine

A

MOA unknown in ADHDMay involve prefrontal cortex activity like Intuniv

107
Q

Indications and dosing for Kapvay?

A
  • Age indication: 6-17 years old
  • 0.1- 0.4 mg/day (bid)
  • Swallow whole
  • Taper over 3-7 days
  • Mono or adjunct tx with stimulants!
108
Q

SEs of kapvay

A
  • Similar to Intuniv
  • Bradycardia
  • Somnolence, etc.
109
Q

Intuniv vs kapvay

A

BID as opposed to Intuniv which is QD. Also good for hyperactivity.Like Intuniv, Combine w/stimulant for attention

110
Q

What needs to be discussed when initiating medication for adhd?

A
  • Clear discussion parent and patient
  • Needs
  • Expectations
  • Targeted outcomes
  • Side effects
  • FMH
  • Personal history
  • Plan for follow up
  • Contract
111
Q

Considerations when choosing a medication for adhd?

A 
Subtype
Issues with “quality of life”
Short acting vs long acting
Delivery method
Start low, titrate up
112
Q

cautions when Rxing stimulants

A

Controlled substances

  • DEA number, 1mo supply, not called in
  • High risk behaviors
  • Other meds/drugs
  • Caffeine and energy drinks
  • Selling, sharing, abusing
  • Parental monitoring of meds
113
Q

When / how to follow up after initiating adhd meds

A 
Phone check: 2 weeks
Office visit: 1 month
Effectiveness
Side effects
Need for dose change or type or class change
HR, BP, weight, neuro
114
Q

How should regular f/u be conducted w/adhd on medication?

A
  • Appropriate, effective, well tolerated dose
    See q 3 months

School and home info

  • Progress, efficacy, concerns
  • VS, HT, WT, neuro
  • Review expectations
  • Rescreen with Vanderbilt F/ U forms
  • Adjust management as needed
115
Q

Why mightmed aherence be decreased in teens?

A
  • 48% adolescents stop meds
  • Deny problem
  • Issues of independence
  • Parents less willing to insist or administer
  • 4.5 Rx filled/year!!!
116
Q

What might increase adherence in teens?

A
  • Better self concept
  • Stable family
  • Internal locus of control
  • Increased motivation
  • Simplified medication regimes
  • Fewer adverse effects
  • Use of motivational interviewing
117
Q

Some CAM / alternative approaches to adhd?

A

Dietary changes

  • Additives
  • Sugars
  • Herbs
  • Omega 3 Fatty Acids
  • Zinc
  • Iron/vitamins
  • Relaxation training
  • Cerebellar training
  • Neuromapping
  • Optometry
  • Exercise
  • Outdoor activity
    Chamomile and valerian ok for restlessness, concentration and sleep issues. Kava kava has adverse effects on CNS with chronic useNo support of megadose of vits/minerals – should treat iron deficiency
118
Q

options for educational intervention in adhd?

A

Individuals with Disabilities Education Act (funding)

  • Services for disabilities that affect educational performance

504 Sec of Rehabilitation Act ( no $)

  • Prohibits discrimination against anyone with disability
  • Regular class, spec services, (FAPE)
    can be very creative to meet needs, motor breaks, etc
119
Q

What is a 504 plan?

A

Provides accommodations, modifications in regular classroom

  • Preferential seating
  • Extended time
  • Modified assignments
  • Alternative test setting
  • Overflow activity
  • Motor breaks
120
Q

What is an individualized education plan (IEP)?

A
  • Legal document (IDEA)
  • Updated annually at Planning and Placement Team (PPT)
    Resource room
  • Resource support
  • Remedial help
  • Tutorials
  • Study skills training
  • etc.
121
Q

Components of F/U for adhd

A

Criteria for efficacy

  • Educational
  • Behavioral
  • Social
  • Pharmacologic
  • Family

Communication

  • Parents
  • Teachers
  • Students
    Other professionals
  • Phone
  • Office visits
  • Repeat checklists/rating scales
122
Q

Outcomes of effective assessment and mgmt?

A
  • Improved self esteem
  • Improved learning outcomes
  • Improved family harmony
  • Improved social skills
  • Improved educational/
  • vocational opportunities
123
Q

Pediatrics: KAS from subcommittee on adhd

A

1 – The PCC should evaluate for ADHD if 4-18yo

2 – DSM-IV (now 5) criteria should be met for Dx. Info primarily from parents/guardians, teachers, other school and mental health clinicians involved in child’s care. R/O alternative cause

3 – PCC should assess for coexisting conditions (anxiety, dep, ODD, CD, learning/language DO, neurodvptl do, tics, OSA)

4 – PCC to recognize ADHD as chronic dz. Follow chronic care model and medical home

5 – Tx varies by age. PCC recs:
• Preschool (4-5yo): behavioral tx as 1st line and Rx methylphenidate if no significant improvement and mod-severe continuing disturbance in child’s function.

• Elementary (6-11yo): FDA approved med and/or behavioral tx, preferably both. Evidence strong for stimulants, sufficient for atomexetine, ER guanfacine, ER conidine (in that order). The school, program, or placement is part of any tx plan.

• Adolescents (12-18yo): FDA approved meds w/assent of adolescent, and maybe behavioral tx , preferable both

6 – titrate doses of meds for adhd to achieve maximum benefit w/minimum adverse effect

Spring Child (3 decks)

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