Faculty Forum

Attention Deficit Hyperactivity Disorder (ADHD)

DR. MARGARET GOPAUL, PH.D., MSCP

I was recently asked to contribute to a book chapter: “Attention Deficit Hyperactivity Disorder (ADHD),” in Principle-Based Stepped Care and Brief Psychotherapy for Integrated Care Settings (Springer, Cham, 2018). Overall, the book aims to provide practitioners with evidence-based treatments for many of the clinical problems encountered within integrated care settings. Central to the book is a bestpractice template for providing behavioral stepped care in medical settings, including screening and assessment, levels of intervention and treatment, referrals, and collaboration with primary care and other specialties. Using this format, contributors detail science-based interventions for a diverse range of common conditions and issues, including depression; anxiety disorders; adherence to chronic obstructive pulmonary disorder management; alcohol and other substance misuses; ADHD; chronic pain; neurocognitive disorders; paraphilia; problematic sexual interests; and sexual abuse and posttraumatic stress disorder (PTSD) in children.

BOOK CHAPTER SUMMARY:

ADHD is believed to be the most frequently diagnosed childhood mental health disorder in the world (Furman, 2005). A recent meta-analysis investigating worldwide ADHD prevalence in children age 18 and under found an overall pooled estimate of 7.2% (Thomas et al., 2015). The prevalence rate in the United States is even higher. Pastor et al. (2015) found that 9.5% of children in the U.S. aged 4-17 years had been diagnosed with ADHD. That means that approximately 2 million children in the U.S. exhibit symptoms of ADHD, ADHD ranks first in terms of referrals to primary care physicians (Barkley, 2006), and ADHD presents a significant challenge to educational systems (Forness & Kavale, 2002). With this understanding, this chapter on ADHD provides evidence-based approaches for professionals. These evidence-based approaches and principles are rendered in a way that allows a practitioner within an integrated care setting to effectively provide principle-based assessment and care. The focus is on brief therapies, which are mostly 3-5 sessions, often 20-30 minutes (the time frame used most in integrated care).

BOOK CHAPTER TOPICS:

› A brief description of ADHD › Effective ways to screen for ADHD in the primary care setting › How to further assess if a screen returns positive › Evidence-based stepped care and brief psychotherapeutic approaches for ADHD › What does not work with ADHD

› When to refer to external specialty mental health › The role of the primary care provider/medical team in treatment

› How to assess the impact on care/quality improvement processes

One of the challenges addressed in this chapter is how to effectively screen for ADHD within a primary care setting. According to the American Academy of Pediatrics (AAP, 2001), primary care offices function as a primary access point for the diagnosis of ADHD for children. Hence, having effective ADHD screening is crucial for timely treatment and interventions. When working with either a child or adult, the provider needs to assess to what extent the individual’s symptoms are influencing moods, behavior, productivity, and lifestyle routines as well as rule out other conditions. Providers should take the following steps to screen for symptoms of ADHD looking at the different domains, age of onset, period of symptoms, and level of functional impairment: › Perform clinical examination to identify other disorders with overlapping symptoms of ADHD. › Interview with individual, parents, caregivers, spouses, teachers, or friends to determine perceptions of ADHD symptoms. › Observe symptoms or behaviors in different settings. › Take note of medical, psychiatric, and developmental history. › Determine related family functional challenges. › Determine the existence of any comorbidity. › Observe patterns of ADHD or related comorbidities shown in the family. › Note age when behaviors started: children, on average, begin displaying symptoms between 3 and 6 years of age.

In adults, note if symptoms occurred in childhood (prior to age 12 years). › Record observations personally, and from teachers for children and adolescents or spouses, parents, or adult siblings. These records are helpful to confirm symptoms reported in interview. Obtain behavior report, report cards, and samples of schoolwork from child’s teacher or classroom observation (if feasible). › Present appropriate screening questionnaires or rating scales to evaluate general behavior and psychosocial functioning, ADHD symptomatology, and comorbidities for at least two sources (typically parent(s) or caregiver(s) and the teacher(s) (NICE, 2008).

It is helpful to be aware of the common ADHD-specific rating scales for children, adolescents, and adults, which are discussed further in the book chapter. For more information, contact

Dr. GoPaul at mgopaul@liberty.edu.