CE/CME

ADHD: Screening, Diagnosis and Management

Welcome to the training on ADHD: Screening, Diagnosis and Management provided by the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).

Credit Hours: 1.25 CE

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Overview
Appendix/Resources

Goal

The goal of this module is to equip Texas Health Steps providers and other health-care professionals to recognize attention-deficit/hyperactivity disorder (ADHD) in children and adolescents and to provide guidelines for diagnosis, management, referral and continuity of care in the medical home.

Target Audience

Texas Health Steps providers and other interested health-care professionals.

Specific Learning Objectives

After completing the activities of this module, you will be able to:

Assess common risk factors and clinical features of ADHD.
Specify how to conduct routine screening, respond to concerns expressed by parents and caregivers and perform diagnostic testing for ADHD.
Summarize the importance of managing patients with ADHD in the medical home.
Determine when to refer patients with ADHD to a specialist or subspecialist.

Note: In this course, the term "parent" also refers to guardians and other caregivers.

Please note this module expires on 7/27/2023.

This module was released on 7/27/2020.

References

Featured

Adelman, R. D., Tmanova, L. L., Delgado, D., Dion, S., & Lachs, M. S. (2014). Caregiver Burden: A Clinical Review. JAMA, The Journal of the American Medical Association, 311(10), 1052-1060.
American Academy of Child and Adolescent Psychiatry. (2020). ADHD and the Brain.
American Academy of Pediatrics, healthychildren.org. (2020). Non-Stimulant Medications Available for ADHD Treatment.
American Academy of Pediatrics, Section on Integrative Medicine (2016). Mind-Body Therapies in Children and Youth. Pediatrics, 138(3), e20161896.
American Academy of Pediatrics, Council on Children With Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, & Medical Home Initiatives for Children With Special Needs Project Advisory Committee. (2006; reaffirmed 2014). Clinical Report: Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics, 118, 405-420.
American Academy of Pediatrics. (2002, reaffirmed 2008). Policy Statement: The Medical Home. Pediatrics, 110:184–186
American Academy of Pediatrics. (n.d.). Mental Health Screening and Assessment Tools for Primary Care. ADHD scales.
Biederman, J., Petty, C. R., Woodworth, K. Y., Lomedico, A., Hyder, L. L., & Farone, S. V. (2012). Adult outcome of attention-deficit/hyperactivity disorder: a controlled 16-year follow-up study. Journal of Clinical Psychiatry, 73(7), 941-50.
Centers for Disease Control and Prevention. (2020). Attention-Deficit/Hyperactivity Disorder, Symptoms and Diagnosis.
Centers for Disease Control and Prevention. (2020). Treatment of ADHD.
Centers for Disease Control and Prevention, National Interview Health Survey 2016-2018. (2020). Racial and Ethnic Differences in the Prevalence of Attention-deficit/Hyperactivity Disorder and Learning Disabilities Among U.S. Children Aged 3–17 Years.
Centers for Disease Control and Prevention. (2019). Attention-Deficit/Hyperactivity Disorder, Data and Statistics.
Centers for Disease Control and Prevention. (2019). Milestones in Action.
Centers for Disease Control and Prevention. (2019). Milestone Tracker app.
Centers for Disease Control and Prevention. (2019). Parent Training in Behavior Management for ADHD.
Centers for Disease Control and Prevention. (2015). Use of Complementary Health Approaches Among Children Aged 4–17 Years in the United States: National Health Interview Survey, 2007–2012. National Health Statistics Reports No. 78.
Centers for Disease Control and Prevention. (2015). Association Between Diagnosed ADHD and Selected Characteristics Among Children Aged 4–17 Years: United States, 2011–2013. NCHS Data Brief No. 201.
Chen, M., Lan, W., Bai, Y, Huang, K., Su, T., Tsai, S., . . . Hsu, J. (2016). Influence of Relative Age on Diagnosis and Treatment of Attention-Deficit Hyperactivity Disorder in Taiwanese Children. Journal of Pediatrics, 172, 162-7.
Child Mind Institute. (2020). Side Effects of ADHD Medication.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). (2020). Myths and Misunderstandings.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). (2017). About ADHD.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). (2017). Detox diet for ADHD? Not so fast!
Danielson, M. L., Bitsko, R. H., Ghandour, R. M., Holbrook, J. R., Kogan, M. D., & Blumberg, S. J. (2018). Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. Journal of Clinical Child and Adolescent Psychology, 47(2), 199-212.
Hamed, A. M., Kauer, A. J., & Stevens, H. E. (2015). Why the Diagnosis of Attention Deficit Hyperactivity Disorder Matters. Frontiers in Psychiatry, 6, 168.
Hiscock, H., Sciberras, E., Mensah, F., Gerner, B., Efron, D., Khano, S., & Oberklaid, F. (2015). Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. British Medical Journal, 350, h68.
Hoogman, M., Bralten, J., Hibar, D., Mennes, M., Zwiers, M., Schweren, L., . . . Franke, B. (2017). Subcortical brain volume differences in participants with attention deficit hyperactivity disorder in children and adults: a cross-sectional mega-analysis. The Lancet Psychiatry, 1(4), 310-319.
Houck, G., Kendall, J., Miller, A., Morrell, P., & Wiebe, G. (2011). Self Concept in Children and Adolescents with ADHD. Journal of Pediatric Nursing, 26(3), 239–247.
My Little Villagers. (2015 video).
National Alliance for Caregiving.
National Institute for Children’s Health Quality. Vanderbilt Assessment Scales.
Perera, F. P., Chang, H., Tang, D., Roen, E. L., Herbstman, J., Margolis, A., . . . Rauch, V. (2014). Early-Life Exposure to Polycyclic Aromatic Hydrocarbons and ADHD Behavior Problems. PLOS One, 9(11), e111670.
Peterson, B. S., Rauh, V. A., Bansal, R., Hao, X., Toth, Z., Nati, G., . . . & Perera, F. (2015). Effects of Prenatal Exposure to Air Pollutants (Polycyclic Aromatic Hydrocarbons) on the Development of Brain White Matter, Cognition, and Behavior in Later Childhood. JAMA Psychiatry, 72(6),531-540.
Stern, A., Agnew-Blais, J., Danese, A., Fisher, H. L., Jaffee, S. R., Matthews, T., Polanczyk, G. V., & Arseneault, L. (2018). Associations between abuse/neglect and ADHD from childhood to young adulthood: A prospective nationally-representative twin study. Child Abuse & Neglect, 81, 274–285.
Texas Department of Family and Protective Services. (2020). Child Protective Services.
Texas Department of State Health Services. Case Management for Children and Pregnant Women.
Texas Department of State Health Services. Case Management Providers for Children and Pregnant Women.
Texas Education Agency. Special Education Rules and Regulations.
Texas Health and Human Services Commission. Early Childhood Intervention.
Texas Health and Human Services Commission. Find your local mental health or behavioral health authority.
Texas Health and Human Services Commission. Take Time Texas.
Texas Medicaid & Healthcare Partnership. (2020). Texas Medicaid Provider Procedures Manual.
University of Michigan: Michigan Medicine. (2019). Overview of Complementary and Alternative Medicine Associated with ADHD. UMHS Attention Deficit Disorder Guideline.
Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., . . . AAP Subcommittee on Children and Adolescents with Attention-Deficit/Hyperactivity Disorder. (2019). Clinical Practice
Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics, 144(4), e20192528.

Medical Definitions

The medical definitions provided in this module were adapted or obtained from ADDitude, American Heart Association, Cognifit, Encyclopaedia Britannica, Fraxa Research Foundation, Healthline, KidsHealth from Nemours, MedlinePlus, Texas Education Agency and U.S. Department of Education.

Accreditation Statements

Continuing Medical Education

The Texas Department of State Health Services, Continuing Education Service is accredited by the Texas Medical Association to provide continuing medical education for physicians.

The Texas Department of State Health Services, Continuing Education Service designates this enduring material for a maximum of 1.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Texas Department of State Health Services, Continuing Education Service has awarded 1.25 contact hour(s) of Continuing Nursing Education.

Social Workers

The Texas Department of State Health Services, Continuing Education Service under sponsor number CS3065 has been approved by the Texas State Board of Social Worker Examiners to offer continuing education contact hours to social workers. The approved status of The Texas Department of State Health Services, Continuing Education Service expires annually on December 31. The Texas Department of State Health Services, Continuing Education Service has awarded 1.25 contact hour(s) of Continuing Social Work Education.

Certified Health Education Specialists

Sponsored by The Texas Department of State Health Services, Continuing Education Service, a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is designated for Certified Health Education Specialists (CHES) and/or Master Certified Health Education Specialists (MCHES) to receive up to 1.25 total entry-level Category I contact education contact hours.

Licensed Marriage and Family Therapists

The Texas Department of State Health Services, Continuing Education Service is an approved provider (#1039) by the Texas State Board of Examiners of Marriage and Family Therapists to offer continuing education contact hours to Licensed Marriage and Family Therapists. The Texas Department of State Health Services, Continuing Education Service has awarded 1.25 contact hour(s) for Licensed Marriage and Family Therapists.

Licensed Professional Counselors

The Texas Department of State Health Services, Continuing Education Service is an approved provider (#690) by the Texas State Board of Examiners of Professional Counselors to offer continuing education contact hours to Licensed Professional Counselors. The Texas Department of State Health Services, Continuing Education Service has awarded 1.25 contact hour(s) for Licensed Professional Counselors.

Certificate of Attendance

The Texas Department of State Health Services, Continuing Education Service has designated 1.25 hour(s) for attendance.

Disclosures

General Disclosure

One of the requirements of continuing education is disclosure of the following information to the learner:

Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
- Create a Texas Health Steps account.
- Complete on-line registration process.
- Thoroughly read the content of the module.
- Complete the on-line examination.
- Complete the evaluation.
Commercial Support.
The THSTEPS Web-based Continuing Education Series has received no commercial support.
Disclosure of Relevant Financial Relationships.
The THSTEPS Continuing Education Planning Committee and the authors of these modules have no relevant financial relationships to disclose.
Non-Endorsement Statement.
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
Off-Label Use.
Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).

The following are policies and definitions of terms related to continuing education disclosure:

The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.

All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.

Glossary of Terms

Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.

Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.

Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).

Browser Requirements

Texas Health Steps courses are best viewed using a current browser. If you are using an out-of-date browser or a version of Internet Explorer less than 11, lesson progress and interactive features may not function properly.

Resources

American Academy of Pediatrics Bookstore. (2019). Caring for Children With ADHD: A Practical Resource Toolkit for Clinicians, 3rd Edition.
American Academy of Pediatrics. (2019). Implementing the Key Action Statements: An Algorithm and Explanation for Process of Care for the Evaluation, Diagnosis, Treatment, and Monitoring of ADHD in Children and Adolescents, which contains the AAP’s algorithm steps.
American Academy of Pediatrics, Bright Futures Developmental, Behavioral, Psychosocial, Screening, and Assessment Forms.
American Academy of Pediatrics, Bright Futures’ section on ADHD.
American Academy of Pediatrics. Bright Futures comprehensive website, offering tools for both practitioners and parents.
Birth to 5: Watch Me Thrive! U. S. Department of Health and Human Services. Helps families and providers identify concerns and developmental delays early and promotes universal screening.
Centers for Disease Control and Prevention. Behavior therapy for young children with ADHD. Finding a Therapist.
Centers for Disease Control and Prevention. Developmental Milestones Checklist and Milestones in Action photos and videos.
Centers for Disease Control and Prevention. (2019). Treatment of ADHD. My Child Has Been Diagnosed with ADHD—Now What?
Centers for Disease Control and Prevention. (2019). Parent Training in Behavior Management for ADHD.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). Parenting a Child with ADHD.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). National Resource Center on ADHD videos on nutrition for ADHD.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). National Resource Center on ADHD training programs, videos, and tips for educators.
Positive Discipline website. Books and videos from Jane Nelsen, Ed.D.
Rabiner, D. (n.d.). ADHD Monitoring System forms from Duke University.
Texas Education Agency. (2019). Early Childhood Special Education. Services for Texas Students with Disabilities Ages 3-5.
Texas Health Steps Mental Health Screening Tools. Links to the tools can be found on the AAP’s Bright Futures web page for Developmental, Behavioral, Psychosocial, Screening, and Assessment Forms.
Texas Health Steps Periodicity Schedule.
Texas Health and Human Services Commission. Take Time Texas. Information about and resources for respite care.
Texas Health and Human Services Commission. Case Management Providers for Children and Pregnant Women, Make a Referral to Case Management.
Texas Health and Human Services Commission. Find Your Local Mental Health or Behavioral Health Authority.
Texas Medicaid & Healthcare Partnership (TMHP) Online Provider Lookup.
The Incredible Years evidence-based behavior programs for parents, children and teachers.
Triple P - Positive Parenting Program with resources for health-care providers and parents.

Families

American Academy of Child and Adolescent Psychiatry. (2020). ADHD Resource Center.
American Academy of Child and Adolescent Psychiatry. (2020). Youth Resource Center.
American Academy of Child and Adolescent Psychiatry. (2018). Family Resources.
American Academy of Child and Adolescent Psychiatry. (2020). Facts for Families.
Centers for Disease Control and Prevention. (2019). ADHD Materials and Multimedia.
Centers for Disease Control and Prevention. (2019). Milestones in Action.
Centers for Disease Control and Prevention. (2019). Milestone Tracker app.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). (2020). For Educators.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). (2020). For Parents and Caregivers.
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). National Resource Center on ADHD videos on nutrition for ADHD.
National Alliance for Caregiving.
National Center for Learning Disabilities
Parent-Child Interaction Therapy International provides extensive resources for parents and professionals on PCIT.)
Partners Resource Network provides parents in Texas resources about their child's disability and rights and responsibilities under IDEA.
Positive Discipline is a program for parents, teachers, and parent educators to teach children social-emotional skills.
Psych Central. Parenting Kids with ADHD: 16 Tips to Tackle Common Challenges.
Texas Department of State Health Services. Case Management Providers for Children and Pregnant Women.
Texas Department of State Health Services. Children with Special Health Care Needs (CSHCN) Services Program. Family Support Services.
Texas Education Agency. Early Childhood Special Education.
Texas Health and Human Services Commission. Aging and Disability Resource Centers (ADRC). Visit the ADRC website for a list of resource center locations in Texas.
Texas Health and Human Services Commission. Early Childhood Intervention.
Texas Health and Human Services Commission. Help Coordinating Your Services.
Texas Health and Human Services Commission. STAR Medicaid Managed Care Program.
Texas Health and Human Services Commission. STAR Kids.
Texas Health and Human Services Commission. Take Time Texas. Includes a state inventory of respite services.
Texas Health and Human Services Commission. Navigate Life Texas.
Texas Parent to Parent provides support, information, and education for families of children of all ages who have disabilities or chronic illness.

Scales

ADHD Scales

ADHD Rating Scale—5 for Children and Adolescents
Conners Rating Scales
NICHQ Vanderbilt Assessment Scales. The scales can be obtained free from the National Initiative for Children’s Healthcare Quality (NICHQ) or by purchasing them as part of the AAP’s ADHD – Caring for Children With ADHD: A Practical Resource Toolkit for Clinicians, 3rd Edition.
Swanson, Nolan and Pelham (SNAP) Scale

Broadband rating scales