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Evidence Based Practices for Mental Health Professionals

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS


Chapter 4 Attention Deficit Hyperactivity Disorder (ADHD)

LEARNING OBJECTIVES FOR

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

After reading this section you will learn the answers to the following questions:

  1. What are the ICD-10-CM Codes for Attention Deficit Hyperactivity Disorder (ADHD)?
  2. What are the clinical descriptors for Attention Deficit Hyperactivity Disorder (ADHD)?
  3. What are the symptoms common for Attention Deficit Hyperactivity Disorder (ADHD)?
  4. What are the common populations which are treated for Attention Deficit Hyperactivity Disorder (ADHD)?
  5. What are the common treatment settings for Attention Deficit Hyperactivity Disorder (ADHD)?
  6. What are the Evidence Based Practices for treating Attention Deficit Hyperactivity Disorder (ADHD)?
  7. What area the common psychopharmacological treatments for Attention Deficit Hyperactivity Disorder (ADHD)?
  8. What are some common manuals, guideline books and client workbooks for treating Attention Deficit Hyperactivity Disorder (ADHD)?
  9. What are some good references you can use to learn more in-depth information about Attention Deficit Hyperactivity Disorder (ADHD)?

ICD-10-CM Codes for Attention Deficit Hyperactive Disorder in DSM-5

Specify if: In partial remission and then Specify current severity: Mild,  Moderate, Severe

F90.2 Attention Deficit/Hyperactivity Disorder Combined Presentation

F90.0 Attention Deficit/Hyperactivity Disorder Predominantly inattentive presentation

F90.1 Attention Deficit/Hyperactivity Disorder Predominantly hyperactive/impulsive presentation

F90.8 Other Specified Attention-Deficit/Hyperactivity Disorder

F90.9 Unspecified Attention-Deficit/Hyperactivity Disorder

 

ICD-10-CM Codes for Disruptive, Impulse-Control, and Conduct Disorders

F91.3 Oppositional Defiant Disorder Specify current severity: Mild, Moderate, Severe

F63.81 Intermittent Explosive Disorder

F91.1 Conduct Disorder Childhood-onset Type Specify if: With limited prosocial emotions. Specify Current Severity: Mild, Moderate, Severe

F91.2 Conduct Disorder Adolescent-onset Type Specify if: With limited prosocial emotions. Specify Current Severity: Mild, Moderate, Severe

F91.9 Conduct Disorder Unspecified-onset Type Specify if: With limited prosocial emotions. Specify Current Severity: Mild, Moderate, Severe

F91.9 Unspecified Disruptive, Impulse-Control and Conduct Disorder

 

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Washington, DC: Author.

Bradford: Attention Deficit/Hyperactivity Disorder


Ms. Smith was concerned, Bradford is one of her better students, but of late she recognized that he was always running late or missing assignments and not being able to handle the multiple choice tests she used to test how well her students understood their assigned readings. She asked Bradford who was 11 why he was not able to get things done on time and why he was doing so poorly on his reading comprehension tests, he said: “Ms Smith, I have no idea, I have always been this way and you are the first person to ever ask me this question.” Ms Smith was alarmed by this news and contact Bradford’s parents and asked them to come in for a parent-teacher conference.


Bradford’s father opened the session saying that Bradford has been diagnosed with ADHD predominantly inattentive type when he was in second grade and his pediatrician put him on Adderall. But last year for fear that Bradford could become addicted to stimulant medication the parents decided to stop giving him the medications. They expressed great concern about how that decision could have really hurt his chances in school. Ms Smith reassured Bradford’s parents and suggested the following course of action:

  1. Have Bradford tested by as school or clinical psychologist to rule out other factors which might account for his decline in productivity in fifth grade. She said the testing would rule out intellectual deficits, learning or processing deficits and possibly support that indeed Bradford still had ADHD predominantly inattentive type.
  2. Once ADHD is ruled in that he would then go to a pediatric neurologist to see if Bradford had any neurological condition which might explain why he is so distracted and inattentive and if such conditions are ruled out, if the physician could suggest a non-stimulant medication to help Bradford regain his focus in school.
  3. While they are in the process of getting Bradford evaluated that they join a parent support group focused on parents of children with ADHD so that they can learn about behavioral and non-medical solutions in dealing with inattention and distractibility.


Bradford’s parents agreed that this sounded like a plan and they would immediately get to work at making it happen. The parents admitted that they knew nothing about ADHD except what the pediatrician had told them and they never heard of non-stimulant medications to use for ADHD.


Give the parent the following plan of action to follow as they pursue the goals you set out for them

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder which involves problems with inattention, working memory (Melby-Lervag and Hulme, 2012) and hyperactivity (impulsiveness) inconsistent with the child’s age, adolescent (Edwards, 2002) or adult (Wadsworth and Harper, 2007). A minimum of 4 to 5% of children in the United States will be diagnosed with ADHD (Golden, 2009). ADHD has no clear scientific test which clinicians can use to definitely confirm an individual has it (Baldwin, 2002; Pelham, Fabiano and Massetti, 2005). Researchers are trying to find the genetic basis for ADHD but have been unsuccessful to date (Cornish, 2008). It is also a fact that ADHD symptoms overlap with other conditions, some which are biologically, psychologically and organically based (e.g. Autism Spectrum, Impulse control and Conduct Disorders, Learning Disabilities, Gifted). Clinicians must rule these out prior to giving an ADHD diagnosis (Baldwin, 2002; Schlachter, 2008). Currently, there are a significant number of children who are referred to mental health providers because teachers or parents suspect them to have ADHD. This significantly impacts children’s families, school, social and personal functioning (Edwards, 2002; Sexton, Gelhorn, Bell and Classi, 2012) and in some cases, the juvenile delinquent system (von Polier, Vloet and Herpertz-Dahlmann, 2012).


There are currently three Evidence Based Practices for treating ADHD:

1) Medication only (Kirkpatrick, 2005; Kollins and Greenbill, 2009; Swanson and Volker, 2009; Wigal, 2009; Maneeton, Maneeton, Srisurapanont and Martin, 2011: Wu, Hodgkins, Ben-Hamadi, Setyawan, Xie, Sikirica, Du, Yan, and Erder, M.H. 2012; Prasad, Brogan, Molvaney, Grainge, Santon and Sayal, 2013; Hautmann, Rothenberger and Dopner, 2013).

Medications used for ADHD

Classification

Drug Name (Generic Name)

Methylphenitdate

Ritalin (Methylphenitdate)   

Ritalin SR Ritalin LA 
Metadate and Concerta (Methylphenitdate)   

Dextroamphetamine

Dexedrine

(Dextroamphetamine)

Dextroamphetamine

/amphetamine salts

Adderall (Dextroamphetamine /amphetamine)

Adderall XR

Dexmethylphenidate

Focalin (Dexmethylphenidate)

Focalin XR

Buproprion

Wellbutrin (Buproprion)

Wellbutrin SR

Atomoxetine NRI

Non-stimulants

Strattera (Atomoxetine HCI)

Intuniv (Guanfacine)

Guanfacine

Intuniv

2) Behavioral intervention only which consists of both individual and group parent training, school-based intervention which involves teacher consultation and classroom behavioral management with parent-teacher daily reports shared and in home interventions (Pelman and Gagney, 1999; Raggi and Chronis, 2006; Leslie, Lambros, Aarons, Haine and Hough, 2008) which can also involve Cognitive Behavioral Therapy (CBT) with college age students (Ramsay and Rostain, 2006) and adults with ADHD (Ramsay, 2010, Weiss, Murray, Wadell, Greenfield, Giles and Hechtman, 2012; Ramsay, 2012, Bolea, Adamou, Arif, Asherson, Gudjonsson, Muller, Nutt, Pitts, Thome and Young, 2012).


3) Combination of medication and behavioral intervention (Hoffman, 2009). Clinicians have found that the combination treatment of medication and behavioral intervention are most successful in addressing the ADHD symptomotology (Edwards, 2002; Johnson and Safranek, 2005; Pelham and Fabiano, 2008).

Assignment given Bradford’s Parents after their first appointment


Parental Plan of Action for their child diagnosed with ADHD


As parents of a child with ADHD we each commit to the following rules of the road:


I will admit there is a problem and go to the proper sources for help:

  • To appropriate agencies (city, county, state, or national)
  • To appropriate professionals (physicians, psychologists, physical therapists, occupational therapists, audiologists, speech therapists, etc.)
  • To appropriate programs and schools (for training the child and/or family members)


Accept my child as my child is:

  • Let up on pressuring or expecting  normal development or learning patterns and responses
  • Stop trying to fix my child. Instead, help child in the ways the child can develop (For example, ask or tell child one thing at a time)
  • Praise my child
  • Set goals and praise my child for each small accomplishment, and take the large goals I have for my child and break them down to workable objectives or action steps which are attainable given my child’s capacity to learn and develop
  • Don't dwell on my child’s failures.
  • Find my child’s strengths and strong points and emphasize them.


Be there when my child needs me:

  • Really listen to my child. My child is saying ''help me'' when my child misbehaves.
  • Don't let other children or adults make fun of my child or how my child is developing.
  • If others make fun of my child, I will try to educate these people as well as try to explain to my child that the world is a “hard” or “mean” place and that people don’t always act nicely towards people whom they do not understand fully what is wrong with them or what makes them different from the norm.
  • Plan ahead for my child. I will not put my child in a setting that would do more harm than good.


Learn to have patience:

  • I will give my child short-term tasks, one at a time.
  • As a parent, I will work to understand my child.


Properly discipline my child:

  • I will be consistent.
  • I will set short-term consequences and stick to them consistently.
  • I will give positive reinforcements for good conduct, like a special privilege, but keep it simple.
  • I will keep track of my child’s progress to encourage behavior that is expected.
  • I will not dwell on behavioral failures.
  • I will only reinforce for behavioral successes.


I agree to the above behavioral model for working with my child

Signed                                                 Date

 

Adapted from: Chapter 1 Handling the Shock of Diagnosis in: Tools for Parent with Children with Special Needs, retrieved at: www.coping.us

Some clinicians have expressed concern that children with ADHD who have been put on medications either alone or with behavioral interventions might likely grow up to become drug or substance abuser, but there has not been any solid evidence to support this contention (Golden, 2009). There has been a great deal of research and success in developing medications which are longer lasting and/or not stimulants to treat ADHD (May and Kratochvil, 2010).

Workbooks for Parents with Children with ADHD

 

Knapp, S.E. (2005). Parenting skills homework planner. Hoboken, NJ: John Wiley & Sons, Inc.

 

Knapp, S.E. and Jongsma, A.E. (2005). The parenting skills treatment planner. Hoboken, NJ: John Wiley & Sons.

 

Messina, J.J. (2013). Pathfinder parenting: Tools for raising responsible children. Retrieved at: http://coping.us

 

Messina, J.J. (2013). Tools for parents with children with special needs, Retrieved at: www.coping.us

 

Miltenberger, R.G. (2008). Behavior modification-principles and procedures, fourth edition. Belmont, CA: Thomson Higher Education.

 

Sailor, W., Dunlap, G., Sugai, G. and Horner, R. (2009). Handbook for positive behavior support. New York: Springer

 

Wells, K.C., Lochman, J.E. and Lenhart, L.S. (2008). Coping power-parent group program. New York: Oxford University Press.

References on ADHD


Baldwin, L. (2002). Keep taking the tablets? Evidence-based approaches to ADHD, Part 1: The

evidence. Paediatric Nursing, 14(3), 22-23.

 

Bolea, B., Adamou, M., Arif, M., Asherson, P., Gudjonsson, G., Muller, U., Nutt, D.J. Pitts,

Thome, J. and Young, S. (2012). ADHD matures: time for practitioners to do the same? Journal of Psychopharmacology, 26(6), 766-770. DOI: 10.1177/0269881111410898

 

Cornish, K.M., Wilding, J.M. and Hollis, C. (2008). Visual search performance in children

rated as good or poor attenders:The differential impact of DAT 1 genotype, IQ, and chronological age. Neuropsychology, 222(2), 217-225. DOI: 10.1037/0894-4105.22.2.217

 

Edwards, J. (2002). Evidence-based treatment for child ADHD: Real-world practice

implications. Journal of Mental Health Counseling, 24(2), 126-139. 

 

Golden, S.M. (2009). Does childhood use of stimulant medication as treatment for ADHD affect

the likelihood of future drug abuse and dependence? A literature review. Journal of Child and Adolescent Substance Abuse 18, 343-358. doi: 10.1080/10678280903185500 

 

Hautmann, C. Rothenberger, A. and Dopner, M. (2013). An observational study of response

heterogeneity in children with attention deficit hyperactivity disorder following treatment switch to modified-release methylphenidate. BMC Psychiatry, 13, 219-229. doi:10.1186/1471-244X-13-219

 

Hoffman, M.T. (2009). Medication, behavioral, and combination treatments for school-aged

children with ADHD. Current Medical Literature: Pediatrics,22(2), 33-40.

 

Johnson, L.S. and Safranek, S. (2005). What is the most effective treatment for ADHD in

children? Journal of Family Practice, 54(2), 166-168. 

 

Kirkpatrick, L. (2005). ADHD treatment and medication: What do you need to know as an

educator? Delta Kappa Gamma Bulletin, 72(1), 19-24. 

 

Kollins, S.H. and Greenbill, L. (2006). Evidence base for use of stimulant medication in

preschool children with ADHD. Infants and Young Children, 19(2), 132-141. 

 

Leslie, L.K., Lambros, K.M., Aarons, G.A., Haine, R.A. and Hough, R.L. (2008). School-based

service use by youth with ADHD in public-sector settings. Journal of Emotional and Behavioral Disorders, 16(3), 163-177. DOI: 10.1177/1063426608314290

 

Maneeton, N., Maneeton, B., Srisurapanont, M. and Martin, S.D. (2011). Buproprian for adults

with attention-deficit hyperactivity disorder: Meta-analysis of randomized placebo-controlled trials. Psychiatry and Clinical Neurosciences, 65, 611-617. doi:10.1111/j.1440-1819.2011.02264.x

 

May, D.E. and Kratochvil, C.J. (2010). Attention-deficit hyperactivity disorder recent advance in

paediatric pharmacotherapy. Drugs, 70(1), 15-40. doi: 0012-6667/10/0001-0015/$55.55/0 

 

Melby-Lervag, M. and Hulme, C. (2013). Is working memory training effective? A meta-

Analytic review. Developmental Psychology, 49(2), 270-291. DOI: 10.1037/a0028228

 

Pelham, W.E. and Fabiano, G.A. (2008). Evidence-based psychosocial treatments for attention-

deficit/hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology, 37(1), 184-214. doi: 10.1080/15374410701818681 

 

Pelham, W.E., Fabiano, G.A., and Massetti, G. (2005). Evidence-based assessment of attention

deficit hyperactivity disorder in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 34(3), 449-476. 

 

Pelham, W.E. and Gnagy, E.M. (1999). Psychosocial and combined treatments for ADHD.

Mental Retardation and Developmental Disabilities Research Reviews 5, 225-236.

 

Prasad, V., Brogan, E., Molvaney, C., Grainge, M., Santon, W. and Sayal, K. (2013). How

effective are drug treatments for children with ADHD at improving on-task behavior and academic achievement in the school classroom? A systematic review and meta-analysis. European Child and Adolescent Psychiatry, 22(4), 203-216.

 

Raggi, V.L. and Chronis, A.M. (2006). Interventions to address the academic impairment of

children and adolescents with ADHD. Clinical Child and Family Psychology Review, 9(2), 85-111. doi: 10.1007/s10567-006-0006-0 

 

Ramsay, J.R. (2010). CBT for adult ADHD: Adaptations and hypothesized mechanisms of

change. Journal of Cognitive Psychotherapy, An International Quarterly, 24(1), 37-45. doi: 10.1891/0889-8391.24.1.37 


Ramsay, J.R. (2012). “Without a net”: CBT without medication for an adult with ADHD.

Clinical Case Studies 11(1), 48-65. DOI: 10.1177/1534650112440741

 

Ramsay, J.R. and Rostain, A. (2006). Cognitive behavior therapy for college students with

attention deficit hyperactivity disorder. Journal of College Student Psychotherapy, 21(1), 3-20. 

 

Schlachter, S. (2008). Diagnosis, treatment, and educational implications for students with

attention deficit/hyperactivity disorder in the United States, Australia, and the United Kingdom. Peabody Journal of education, 83, 154-169. doi: 10.1080/01619560701649273 

 

Sexton, C.C., Gelhorn, H.L., Bell, J.A. and Classi, P.M. (2012). The co-occurrence of reading

disorder and ADHD: Epidemiology, treatment, psychosocial impact, and economic burden. Journal of Learning Disabilities, 45(6), 538-564. DOI: 10.1177/0022219411407772

 

Swanson, J.M. and Volkow, N.D. (2009). Psychopharmacology: Concepts and opinions about the

use of stimulant medications. The Journal of Child Psychology and Psychiatry 50(1), 180-193. doi:10.1111/j.1469-7610.2008.02062.x 

 

von Polier, G.G. Vloet, T.D. and Herpertz-Dahlmann, B. (2012). ADHD and delinquency-a

developmental perspective. Behavioral Sciences and the Law, 30 121-139. DOI: 10.1002/bsl.2005

 

Wadsworth, J. S. and Harper, D.C. (2007). Adults with attention deficit/hyperactivity

disorder: Assessment and treatment strategies. Journal of Counseling and Development, 85(1), 101-108. 

 

Weiss, M., Murray, C., Wadell, M., Greenfield, B., Giles, L. and Hechtman, L. (2012). A

randomized controlled trial of CBT therapy for adults with ADHD with and without

medication. BCM Psychiatry, 12(30), 1-8. doi:10.1186/1471-244X-12-30

 

Wigal, S.B. (2009). Efficacy and safety limitations of attention-deficit hyperactivity disorder

pharmacotherapy in children and adults. CNS Drugs, 23(1), 21-31. doi: 1172-7047/09/0001-0021 

 

Wu, E.Q., Hodgkins, P., Ben-Hamadi, R., Setyawan, J., Xie, J., Sikirica, V., Du, E.X., Yan, S.Y.

and Erder, M.H. (2012). Cost effectiveness of pharmacotherapies for attention-deficit hyperactivity disorder – A systematic literature review. CNS Drugs, 26(7), 581-600. DOI: n72-7047/i2/0(X)7-OS81/S49,95/0

WHERE DO I GO FROM HERE?

CONCERNING ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

Now that you have read this section, in “My Mental Health Professional Practitioner Journal” record your answers and reactions to the following questions:

  1. How will this information help me as a Mental Health Professional?
  2. How interested am I in implementing Evidence Based Practices concerning ADHD in my clinical practice?
  3. Why is it important that I learn more about ADHD?
  4. What more do I need to know about this ADHD?
  5. Where can I go to obtain more information about ADHD?
  6. Where can I go to obtain the journal articles, manuals, workbooks or guidebooks on ADHD?