BEHAVORIAL HEALTH DEPARTMENT – PRIMARY CARE CENTER AND FIREWEED

TREATMENT GUIDELINES FOR

ADHD

EXECUTIVE SUMMARY ....................................................................................................................2

INTRODUCTION AND STATEMENT OF INTENT .................................................................................................2
DEFINITION OF DISORDER .....................................................................................................................2
GENERAL GOALS OF TREATMENT ..............................................................................................................2
SUMMARY OF 1ST, 2ND AND 3RD LINE OF TREATMENT ......................................................................2
APPROACHES FOR PATIENTS WHO DO NOT RESPOND TO INITIAL TREATMENT .............................................................3
FLOW DIAGRAM..............................................................................................................................4

ASSESSMENT ..................................................................................................................................5
PSYCHIATRIC ASSESSMENT ....................................................................................................................5
PSYCHOLOGICAL TESTING .....................................................................................................................5
SCREENING/SCALES ............................................................................................................................5
MODALITIES & TREATMENT MODELS..............................................................................................6
GROUP THERAPY ................................................................................................................................6
INDIVIDUAL THERAPY ...........................................................................................................................7
FAMILY THERAPY / COUPLES THERAPY........................................................................................................8
INDIVIDUAL MEDICATION MANAGEMENT (5 TO 8 YEARS OLD).............................................................................9
INDIVIDUAL MEDICATION MANAGEMENT (8 TO 18 YEARS OLD) ......................................................................... 10
INDIVIDUAL MEDICATION MANAGEMENT (OVER 18 YEARS OLD) ........................................................................ 11
GROUP MEDICATION MANAGEMENT ......................................................................................................... 12
PSYCHO EDUCATIONAL GROUPS ............................................................................................................. 13
CASE MANAGEMENT .......................................................................................................................... 14
REFERRAL ...................................................................................................................................... 14
PRIMARY CARE ................................................................................................................................ 14
APPENDIX A: GLOSSARY ..............................................................................................................15

APPENDIX B: LITERATURE SUMMARY...........................................................................................17

APPENDIX C: SAMPLE TREATMENT PLANS ....................................................................................20

TREATMENT PLAN FOR ATTENTION DEFICIT / HYPERACTIVITY DISORDER (ADHD)................................................... 20

Revised By: Joanette Sorkin, MD; Jennifer Card, MSW, LCSW; Pam Faille; Carlyn Larsen, MS; Trish Smith
CBG Approval Date: 6/13/2006
PIC Approval Date: 7/6/2006
BHS Treatment Guidelines for ADHD

Executive Summary
Introduction and statement of Intent

This treatment guideline is intended to assist clinicians in the Behavioral Health department in treatment
planning and service delivery for patients with Attention deficit Hyperactivity Disorder (ADHD). It may also
assist clinicians treating patients who have some of the signs and symptoms of ADHD but who do not meet
the full criteria or symptoms are accounted for by another disorder. The treatment guideline is not intended
to cover every aspect of clinical practice, but to focus specifically on the treatment models, modalities,
and/or referrals that clinicians in our outpatient treatment setting could provide. These guidelines were
developed through a process of literature review and discussion amongst clinicians in the Behavioral Health
department and represent a consensus recommendation for service provision for this disorder. The guideline
is intended to inform both clinical and administrative practices with the explicit goals of outlining treatment
that is: Effective, Efficient, Age Appropriate, Culturally Relevant, and Acceptable to clinicians, program
managers, and patients and family

Definition of Disorder
Attention-Deficit Hyperactivity Disorder (ADHD) is defined as an individual having six or more symptoms of
either inattention or hyperactivity, for at least six months, to the extent that it is not conducive and
conflicting with developmental growth. Some of the symptoms that cause impairment must have been
present before the age of seven. Symptoms must be present in two or more settings (home, work or
school). There must be clear evidence of clinical significance showing impairment in social, academic, or
occupational functioning. Symptoms cannot occur exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder and must not be better accounted for
by another mental disorder.

General Goals of treatment

As with treatment of all psychiatric illnesses, the goals of treatment are to reduce or eliminate symptoms
and restore function. For ADHD, remission usually means that attention and distractibility are improved to
the point that the individual can participate and develop, socially, academically, occupationally, and so on.
Goals of treatment may include improvement in attention to the details that are necessary to sustain tasks
or play activities through to completion. An organized and focused thought process with improved memory
function combined with the ability to control impulses is indicative of ADHD symptom stability.

Summary of 1st, 2nd and 3rd line of treatment

ADHD treatment at this time varies according to different ages and/or severity and involves combinations of
Parenting training, Family Therapy, or Individual Therapy, Psychoeductation and Medication Management.

For clients who are diagnosed with ADHD under the age of 12, the first line of treatment would be Family
Therapy to address Parenting techniques and build skills such as limit setting, knowledge of appropriate
developmental expectations/needs, creating a structured environment, etc. Clients from age 5-12 years
would likely benefit from skills groups once parenting skills have been developed, creating a more stable
home environment. The Young Families program may be a consideration for the children under the age of 5
and their families. Medication is not a first line treatment for children under the age of 5 as there are no
specific guidelines and it is highly controversial. The decision to use medication as a treatment should be
determined only after a psychiatric evaluation, on a case by case basis.

Group Therapy is the first line of treatment recommended for clients that range from 12 years of age
through adulthood and have ADHD with symptoms in the mild to moderate severity range. These clients
diagnosed with ADHD would benefit from groups focusing on development of social skills, increased
structure, and affect regulation. Second line of treatment would be medication to help with reduction of
symptoms, but preferably in conjunction with treatment to develop social skills, structure and affect

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 2 of 22
BHS Treatment Guidelines for ADHD

regulation. Individual Therapy would be the third line of treatment for those clients who are not appropriate
for group or need some individual sessions to help prepare them for group.

Clients who are age 5 through adult, diagnosed with ADHD, but have symptoms in the moderate to severe
range; the first line of treatment is a combination of medication management and individual therapy. The
medication would address the severity, stabilizing the symptoms and the individual therapy would work on
building the skills to increase daily functioning. Treatment would focus on developing skills for affect
regulation, setting up an external system for maintaining structure, and increasing social appropriateness.
Once the client is stabilized on medication and has learned some basic skills, he/she would transition into
group therapy.

Note that while medication is frequently used in treatment of ADHD, parenting and environmental issues
should be thoroughly investigated before using medication. Families that have a chaotic family structure or
families at high risk of drug abuse would not be good choices for medication as a first line of treatment. It is
also important to note that medication alone is not likely to solve the client’s impaired functioning,
psychosocial involvement is necessary. Psychoeducation for the patient and/or parent, and family regarding
the diagnosis is essential for the most effective treatment.

Approaches for patients who do not respond to initial treatment

If a patient is not responding well to treatment, the level of compliance with the recommended treatment
should be evaluated (i.e., if the client is a child, and the recommended treatment is a combination of
parenting techniques and medication; are the parents following recommended parenting techniques? is the
child taking his/her medication?). If not, address where the compliance difficulty lies and work on solving
those issues. If the client is in compliance with the recommendations and treatment is still not effective, re-
evaluation of the diagnosis is recommended. This re-evaluation may include a referral for psychological
testing. The client may have a different diagnosis that has similar symptoms or there may be a co-occurring
disorder that also needs treatment.

Clinical and demographic issues that influence treatment planning

The prevalence of Attention Deficit/Hyperactivity Disorder (ADHD) is about 3-5 of all school age children and
probably 30-50% of all the child mental health referrals. There are approximately twice as many boys
diagnosed as girls and about 10-60% of these children will continue to have symptoms in adulthood. The
etiology for ADHD is generally considered both neurological and genetic; with approximately 65% of children
having ADHD also have a relative with ADHD. It’s estimated that about 1/3 of the children diagnosed with
ADHD have co-occurring disorders. Common disorders which co-occur are Conduct D/O, Oppositional Defiant
D/O, Antisocial Personality, and Substance Abuse D/O.

There are several factors that make diagnosing ADHD difficult. Several disorders have similar symptoms,
such as Anxiety, Depression (agitation type), Learning Disorders, and Post Traumatic Stress, as well as
Conduct, Oppositional Defiant and Intermittent Explosive. There are also different presentations for boys and
girls. Boys tend to be more hyperactive and have more behavioral problems. Girls tend to fall in the category
of inattentive, with more social problems or getting lost in their own world.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 3 of 22
BHS Treatment Guidelines for ADHD

Flow Diagram

Assessment Completed

Review
DSM-IV criteria
for this disorder

Does
customer meet
UNCERTAIN YES
criteria for this
disorder?

Reference Assessment in the

Treatment Guidelines
NO
Are
manifestations
Review other diagnoses and/or of this disorder the
NO
treatment guidelines most pressing aspect
of the clinical YES
presentation?
Review case at your
clinical team meeting and
with your clinical supervisor.

Does
customer
Recommend customer for NO want treatment YES
psychiatric Assessment, for this
Psychological Testing and/or disorder?
utilize screening scales to aid
your in our assessment.

Reference
Ensure Patient Safety
Treatment Guidelines

Recommend 4 PM Gatherings,
Read
PsyhoEd groups and/or Primary
Executive Summary
Care (BHC)

Review each
treatment modality

Determine treatment
indicated for this customer.

Customize standard treatment

plans for this customer.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 4 of 22
BHS Treatment Guidelines for ADHD

Assessment
The Diagnostic Testing team will be reviewing and commenting on the Psychological Testing column for
every disorder.

Psychiatric Assessment Psychological Testing Screening/Scales

Indications ! Diagnostic dilemma or ! Diagnostic clarification • Establish
clarification of co-morbidity following assessment by baseline and/or
! Unmanageable behavior or provider in FMC or monitor
other symptoms that have PEDS. treatment
not improved with ! Ensure psychiatric eval effectiveness
standard interventions for adults prior to • Clarify symptoms
! Patients are already on psychological testing. • Recommend
psychotropic medication ! Question only baseline
and is requesting answerable by screenings be
continuation psychological testing completed in
! Patient or guardian ! Appropriate physical FMC and PEDS.
requests a second opinion assessment completed
or wishes to consider
pharmacologic intervention
! Rule out organic cause
and/or contributions to
symptoms

Contraindications ! Diagnosed severe ! Extremely dangerous to ! Limited English

cognitive disorder or self and/or others proficiency.
developmental delay and ! Untreated psychosis (relative contra-
collateral source not ! Initial evaluation / indication)
available assessment is not done ! Lack of
! Consent not available (if ! Referral question not cooperation
patient has guardian) answerable and/or not
! Patient or guardian has clear
forensic rather than ! Any physical causes of
therapeutic goal (i.e. the disorder have not
compliance with court or been ruled out
parole requirements, ! School or other source
disability determination, has already conducted
etc.) psychological testing
within the last year
(relative contra-
indication)
! Severely depressed
! Limited English
proficiency.

Structure In patients with cognitive ! Depends on the referral ! Self-administered

impairment who cannot give question for adults and
adequate history, parent or adolescents
guardian with knowledge of ! Completed by
the patient’s history must be Parent and/or
available for assessment. care giver for
children or
incompetent
adults.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 5 of 22
BHS Treatment Guidelines for ADHD

Modalities & Treatment Models

Group Therapy

RELATIVE
INDICATIONS CONTRAINDICATIONS CONTRAINDICATIONS
! Customer is 5 years old or ! Dangerousness to self or • Diagnosis social phobia (May
older others need individual therapy for
! Mild to moderate severity ! Lack of commitment from group preparation)
! Able to tolerate affect without customer and if customer not • Relatives or significant others
behavior destructive to group competent in the same group (unless it is
! Sufficient verbal and/or ! Sexually acting out behaviors a family group and/or couples
cognitive ability to benefit ! Court ordered treatment with group)
from treatment no buy in from child and/or • Meets CMI or SED criteria
! For customers under 18 years guardian without receiving rehab
old, parental education and ! Child abuse investigation services
involvement is predictive of incomplete • lack of commitment from
good outcome and should be ! Untreated Psychosis or mania parent and/or legal guardian
integrated whenever possible. ! History of chronic or extreme
disruptive behavior in groups
! Untreated substance
dependence
! Acute intoxication or
withdrawal from alcohol or
other substances

STRUCTURE

• Groups will be facilitated by a Master’s Level Therapist and Case Manager

• For 17 years old and below, some age grouping recommended
• For 18 years old and above consider adult services

Duration 60 to 90 minutes for 10 to 15 weeks

Frequency Once a week
Size ! 3 to 9 years old 4 customers per provider
! 10 years old and over 8 to 10 customers per provider
Open vs. Closed Open or Closed with windows

TREATMENT MODEL

! Group Support
! Social Skills Training

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 6 of 22
BHS Treatment Guidelines for ADHD

Individual Therapy

RELATIVE
INDICATIONS CONTRAINDICATIONS CONTRAINDICATIONS
• Group therapy contraindicated ! Imminent dangerousness to ! Lack of commitment from
• Customer is 5 years old or self or others parent and/or legal guardian
older ! Lack of commitment from (case by case basis)
• Moderate to Severe severity customer and if customer not
• Sufficient verbal and/or competent.
cognitive ability to benefit ! Court ordered treatment with
from treatment no buy in from child and/or
• Unable to tolerate affect guardian
without behavior destructive ! Child abuse investigation
to group incomplete
• Recent sexual, physical, abuse ! Untreated Psychosis or mania
and/or neglect ! Acute intoxication or
• For customers under 18 years withdrawal from alcohol or
old, parental education and other substances
involvement is predictive of
good outcome and should be
integrated whenever possible.

STRUCTURE

Duration 60 minutes
Frequency ! Weekly or Twice a Month
! Up to 8 sessions for treatment

TREATMENT MODEL

! Consider Young Families for anyone under 5 years old

! Medication
! Cognitive Behavioral Therapy
! Psychotherapy
! Neurocognitive Therapy
! Cognitive Rehabilitation

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 7 of 22
BHS Treatment Guidelines for ADHD

Family Therapy / Couples Therapy

RELATIVE
INDICATIONS CONTRAINDICATIONS CONTRAINDICATIONS
! First line of treatment for 0 to ! Imminent dangerousness to ! Custody dispute
5 year old self or others
! Disorder is impacting the ! Lack of commitment from
family and/or relationship customer and if customer not
! Family dynamic exacerbating competent, lack of
or triggering symptoms commitment from parent
! Sufficient verbal and/or and/or legal guardian
cognitive ability to benefit ! Court ordered treatment with
from treatment no buy in from child and/or
! For customers under 18 years guardian
old, parental education and ! Active child abuse
involvement is predictive of investigation incomplete (OCS
good outcome and should be involvement does not preclude
integrated whenever possible. family therapy)
! Concurrent with group and/or ! Current Domestic violence or
individual treatment for abuse of child
children or adults with severe ! Untreated Psychosis
mental illness ! Acute intoxication or
withdrawal from alcohol or
other substances

STRUCTURE

Duration 60 minutes
Frequency ! Weekly or Twice a Month
! Up to 8 sessions for treatment

TREATMENT MODEL

! When Parenting is not sufficient, Family Therapy is highly recommended (with or without child at the
discretion of the clinician).
! Medication
! Cognitive Behavioral Therapy
! Systemic Therapy
! Behavioral Therapy
! Social Skills Training
! Parenting Skills Training

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 8 of 22
BHS Treatment Guidelines for ADHD

Individual Medication Management (5 to 8 years old)

RELATIVE
INDICATIONS CONTRAINDICATIONS CONTRAINDICATIONS
! Parent and/or legal guardian ! Refuses Medication ! Refuses Medication
consent Management Management
! Current biopsychosocial ! Disorder is caused by an ! Disorder is caused by an
intake or psychiatric untreated physiological untreated physiological
assessment is available. disorder. disorder
! Stimulants: psychotic
symptoms, tics, or any
medical condition precluding
use of sympathomimetics.

STRUCTURE

Obtain ADHD symptoms checklist completed by parent.

Duration 30 minutes
Frequency Weekly tapering to monthly with symptom stabilization

TREATMENT MODEL

Treatment with medication of children under 5 years old is highly controversial, there are no specific
guidelines or protocols; a psychiatric evaluation is essential.

Recommended concurrent Structured Behavioral Modification, individual psychotherapy, psychoedcation,

parent counseling, and Psychopharmacology education.

Psychopharmacology recommendations

! First Line – Able to swallow tablets: Methylphenidate (Ritalin), Amphetamine/dextroamphetamine

(Adderall).
! If tolerated well, switch to Methylphenidate ER Concerta) or
Amphetamine/dextroamphetamine XR (Adderall XR).
! Not able to swallow tablets: Fluoxetine (Prozac)
! Second Line – Bupropion (Wellbutrin) or Fluoxetine (Prozac)
! Third line – Atomoxetine (Strattera), Clonidine (Catapres), or Guanfacine HCL (Tenex), Mentadate

*Tenex and Mentadate are not on the SCF formulary.

*Adderall, Ritalin,Cylert, and Strattera are FDA approved for treatment of children with ADHD.
*Wellbutrin, prozac, catapress, and tenex are not FDA approved for treatment of children with ADHD, but
are proven effective in symptom control.

If customer is not responding to treatment, re-evaluate, change diagnosis and/or identify multiple diagnosis
requiring several different medications.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 9 of 22
BHS Treatment Guidelines for ADHD

Individual Medication Management (8 to 18 years old)

RELATIVE
INDICATIONS CONTRAINDICATIONS CONTRAINDICATIONS
! Parent and/or legal guardian ! Parent and/or legal guardian ! Refuses Medication
consent consent Management
! Current biopsychosocial ! Current biopsychosocial ! Disorder is caused by an
intake or psychiatric intake or psychiatric untreated physiological
assessment is available assessment is not available disorder.

STRUCTURE

! Obtain ADHD symptoms checklist completed by parent.

! Obtain ADHD symptoms checklist completed by older children/adolescent.

Duration 30 minutes
Frequency Weekly tapering to monthly with symptom stabilization

TREATMENT MODEL

Recommended concurrent Structured Behavioral Modification, individual psychotherapy, psychoedcation,

parent counseling, and psychopharmacology education.

Psychopharmacology Recommendations

! First Line – Concerta or Adderall

! Second Line – Wellbutrin or Prozac
! Third line – Strattera, Catapres, or Tenex

*Concerta, Adderall, and Strattera are FDA approved for treatment of children/adolescents with ADHD.
*Wellbutrin, Prozac, catapress, and tenex are not FDA approved for treatment of children/adolescents with
ADHD but are proven effective in symptom control.

If customer is not responding to treatment, re-evaluate, change diagnosis and/or identify multiple diagnosis
requiring several different medications.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 10 of 22
BHS Treatment Guidelines for ADHD

Individual Medication Management (Over 18 years old)

RELATIVE
INDICATIONS CONTRAINDICATIONS CONTRAINDICATIONS
! Parent and/or legal guardian ! Refuses Medication ! Refuses Medication
consent Management Management
! Current biopsychosocial ! Disorder is caused by an ! Disorder is caused by an
intake or psychiatric untreated physiological untreated physiological
assessment is available disorder. disorder.
! Stimulants: psychotic
symptoms, tics, or any
medical condition precluding
use of sympathomimetics.

STRUCTURE

! Obtain ADHD symptoms checklist completed by parent.

! Obtain ADHD symptoms checklist completed by older children/adolescent.

Duration 30 minutes
Frequency Weekly tapering to monthly with symptom stabilization

TREATMENT MODEL

Recommended concurrent Structured Behavioral Modification, individual psychotherapy, psychoedcation,

parent counseling, and psychopharmacology education.

Psychopharmacology Recommendations

! First Line with SA in history – Bupropion SR (Wellbutrin SR), Venlafaxine ER (Effexor ER), Atomoxetine
(Strattera).

! First Line without SA in history – Methylphenidate SR, (Ritalin SR), Amphetamine/dextroamphetamine

XR (Adderall XR), Dextroamphetamine (Dexadrine).

! Second Line – Desipramine (Norpramin), Imipramine (Tofranil), Amitriptyline (Elavil).

! Third line – Clonidine (Catapress).

*The only FDA approved drug for adults with ADHD is Atomoxetine (Strattera).
*Wellbutrin, effexor, Ritalin, adderall, norpramin, elavil, and catapress are not FDA approved for treatment
of adult with ADHD but have prioven effective in symptom control.

If customer is not responding to treatment, re-evaluate, change diagnosis and/or identify multiple diagnosis
requiring several different medications. Antidepressants and antipsychotic medications might be considered
in exceptional circumstances.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 11 of 22
BHS Treatment Guidelines for ADHD

Group Medication Management

Need for parent and/or guardian presence makes group medication management impractical for customers 0
to 18 years old.

RELATIVE
INDICATIONS CONTRAINDICATIONS CONTRAINDICATIONS
! If symptoms stable and ! Acute dangerousness to self or • Diagnosis social phobia (May
patient cannot return to others need individual therapy for
primary care for maintenance ! Untreated psychosis group preparation)
treatment, group medication ! Sexually acting out behaviors • Relatives or significant others
management should be ! No child care available in the same group (unless it is
considered. ! Severe untreated a family group and/or couples
! History of non-compliance hyperactivity group)
! Able to tolerate affect without • Meets CMI or SED criteria
behavior destructive to group without receiving rehab
! Frequently misses scheduled services
appointments

STRUCTURE

Groups will be facilitated by a Master’s Level Therapist and Case Manager

Duration 60 minutes
Frequency Once a week
Size 8 to 10 customers per clinician
Open vs. Closed Open

TREATMENT MODEL

Behavioral Modification, psychoeducation, and psychopharmacology education.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 12 of 22
BHS Treatment Guidelines for ADHD

Psycho Educational Groups

RELATIVE
INDICATIONS CONTRAINDICATIONS CONTRAINDICATIONS
! Sufficient verbal and/or ! Dangerousness to self or
cognitive ability to benefit others
from treatment ! Sexually acting out behaviors
! Able to tolerate affect without ! Untreated Psychosis or mania
behavior destructive to group ! History of chronic or extreme
! Could benefit from skills disruptive behavior in groups
development ! Untreated substance
dependence
! Severe untreated
hyperactivity

STRUCTURE

Groups will be facilitated by 1 to 2 Case Managers.

Duration 60 to 90 minutes for up to 8 weeks

Frequency Once a week
Open vs. Closed Open

TREATMENT MODEL

Psycho-educational groups would be behavior modification in nature, with information for developing
parenting skills and social skills.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 13 of 22
BHS Treatment Guidelines for ADHD

Case Management
All Ages
Assessment ! Collect psychosocial history
! Collect collateral history and/or past treatment records
! Obtain patient and/or guardian consent
! Liaison with outside agencies and/or link to community resources
! Administer standardized scales
! Lead orientation to services
! Review and/or conduct client initial screening and triage
Treatment ! Psychosocial education
! Maintain supportive contact
! Triage current clients in crisis
! Crisis management (e.g. triage, risk assessment, skills coaching, referrals when
needed)
! Community liaison work and coordination of care
! Manage charts
! Provide aspects of treatment
! Assist with group preparation
! Draft treatment plans
! Follow-up when customer fails to keep appointments.
! Encourage medication and treatment compliance
Follow-up ! Liaison with outside agencies
! Link to community resources
! Gather and disseminate information from external referral sources

Referral

INDICATIONS

! Services needed are not available within the Behavioral Health department.
! Diagnostic clarification needed for initial diagnosis of ADHD

CONTRAINDICATIONS

Meets criteria for treatment within the Behavioral Health department system

Primary Care
INDICATIONS

! Initial screening and diagnosis done in FMC and PEDS

! Refuses specialty mental health care
! Uncomplicated Medication Management
! Maintenance Medication Management

CONTRAINDICATIONS

Higher intensity services needed to ensure safety to patient or others

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 14 of 22
BHS Treatment Guidelines for ADHD

Appendix A: Glossary
Term or Acronym Term Definition
Acute Intoxication A reversible substance-specific syndrome due to recent ingestion
of (or exposure to) a substance. Clinically significant maladaptive
behavior or psychological changes that are due to the effect of
the substance on the central nervous system and develop during
or shortly after use of the substance. (Adapted from DSM-IV)
Acute Withdrawal A substance-specific syndrome due to the cessation of (or
reduction in) substance use that has been heavy and prolonged.
(Adapted from DSM-IV)
CBT Cognitive Behavioral Therapy
Closed Group Customers may enter only at initial formation of group.
Closed Group with Windows Customer enrollment available intermittently
Eclipse Overshadow, for example, when the symptoms and dysfunction
related to one disorder overshadow another making treatment of
one more pressing.
Exposure Therapy Exposure therapy (Haug et al, 2003) with or without response
inhibition is most cited as effective for specific phobia, obsessive
compulsive disorder and PTSD. Generally, these run 10 -12
sessions with each session targeting a specific skill, exposure
level and cognitive reframing. Manuals are available to guide
clinical work.
Intervention Any thoughtful action taken by a clinician or customer with the
purpose of addressing a perceived problem or therapeutic goal
IPT Interpersonal Therapy
NOS Not Otherwise Specified
Open Group Participants can enter at any time.
PDD Pervasive Developmental Disorder
Play Therapy Play therapy is a form of psychotherapy for children who have
been traumatized. It encourages children to explore their
emotions and conflicts through play, rather than verbal
expression.
Psychiatric Assessment Formal assessment by a psychiatrist or ANP
Psychoeducation teaching and training about the disease or problem for which the
customer or family member is seeking treatment.

Psychoeducation is frequently presumed to be part of all forms of

assessment and treatment, yet additional interventions that
emphasize education about an illness are often shown to improve
outcomes over treatment as usual. Psychoeducation can be
incorporated into many treatments, but can be viewed as an
intervention in its own right and can be delivered by non-
professional staff such as case managers or health educators.
Psychological Testing Formal psychological assessment which includes clinical interview
and appropriate tests conducted by a psychologist and/or
psychometrician. This testing is standardized and normed.
Screening/Scales Brief, easily administered screening and scales which do not
require advance training to interpret.
Social Rhythm Therapy A structured psychotherapy combining elements of behavioral
therapy and psychoeducation and shown to reduce rates of
relapse and rehospitalization in bipolar disorder

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 15 of 22
BHS Treatment Guidelines for ADHD

Term or Acronym Term Definition

Structural Family Therapy (SFT) Structural Family Therapy is model of treatment in which a family
is viewed as a system with interdependent parts. In this
treatment model, the family system is understood in terms of the
repetitive patterns of interaction between the parts. From such a
perspective, the goal of structural family therapy is to identify
maladaptive or ineffective patterns of interactions, then alter
them to improve functioning of the subparts and the whole.
TBI Traumatic Brain Injury
Treatment Modality For purposes of this guideline, we have defined “modality” as the
structure in which the customer receives treatment, for example,
individual psychotherapy, group psychotherapy, or
psychoeducation.
Treatment Model For purposes of this guideline, we have defined the “model” of
care as the underlying theoretical approach to clinical
intervention, for example, Cognitive Behavioral Therapy, Insight
Oriented Therapy, Interpersonal Therapy.
Untreated Psychosis For the purposes of this treatment guideline, we define untreated
psychosis as psychotic symptoms that are prominent, disruptive
in some way, and for which the customer is not accepting or
engaging in care that would mitigate such symptoms. The
diagnosis of a psychotic disorder or the presence of psychotic
symptoms at some point in the course of illness or treatment
should not be a barrier to participation in treatment that might
be helpful. However, nor should a customer with a significant
psychotic disorder be treated with some forms of psychotherapy
from which they are not likely to benefit. Clinical judgment will
be needed in selecting appropriate treatment for each customer.
Untreated Substance Dependence Because “dual diagnosis” is the norm, rather than the exception
in behavioral health settings, customers with substance abuse
problems should not be excluded, a priori, from participation in
treatment for other mental health conditions. However, the
impact of their substance use on their capacity to participate in
treatment must be assessed on an ongoing basis. Customers
with current substance dependence may not be appropriate
candidates for some forms of treatment.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 16 of 22
BHS Treatment Guidelines for ADHD

Appendix B: Literature Summary

Evidence Based Clinical Guidelines
Southcentral Foundation Research Project
Summary Sheet
Attention Deficit/Hyperactivity Disorder

Diagnosis: This summary contains reviewed articles around Attention Deficit/Hyperactivity Disorder.

314. Attention Deficit/Hyperactivity: This disorder is constructed on two parts: Inattention consisting of
problems with listening, following through with instructions, problems organizing and being easily distracted
and Hyperactivity consisting of problems with impulsivity, fidgeting, difficulty waiting turns and frequent
interruptions. There are three subtypes: Combined Type, Predominantly Inattentive, Predominantly
Hyperactive-Impulsive Type.

General Information: This review searched the following data bases: Cochrane Reviews, American
Psychological Association, American Psychiatric Association, The Journal of Empirical Mental Health, The
National Guideline Clearinghouse, The Texas Algorithm Project, The Harvard Algorithm Project and SAMHSA,
NIMH and Mental Health. The keywords for this search were: ADHD, ADD. Attention Deficit, Hyperactivity,
group therapy, group psychotherapy, evidence-based, empirically supported
treatments/therapies/interventions, reviews, and Boolean combinations of such terms.

This search produced significant hits from which a selected group is included. This does not represent a
thorough investigation of the literature. There exist no formal evidence based protocol rather strongly
support clinical guidelines, some empirically supported interventions and some best practices. This category
of disorder necessitates clear assessment, differential diagnostic skills and anchored measurements of
symptoms in order to benefit maximally from interventions. The National Consensus Report on ADHD by
NIMH in 1998 noted that while the core symptoms can be addressed, academic improvement is generally flat
and that mostly reading scores modestly improve.

Group Therapy and ADHD: The Multimodal Treatment Study for ADHD sponsored by National Institute of
Mental Health provides the greatest data on this review and this section. The MAT Comparative group (1999)
noted that group family treatment focusing on parent training was instituted. The groups consisted of six
families per group. While this component (family/parent training) did not affect changes in the ADHD core
symptoms greater than medication or behavioral therapy or combination, it did significantly improve
prosocial functioning and decreased oppositionality. No other references rose to the level of empirically or
evidence based for the use of group therapy. The MTA study, using Pelham’s protocol for summer daily
therapy at camp would presuppose group activities, socialization skills development, and environmental
feedback sessions. Farmer et al., (2002) cites support for parent training, outpatient therapy using modified
CBT and school based treatments. She cites that multifamily therapy has some evidence.
Individual Therapy and ADHD: Root and Resnick (2003) citing a MTA update confirm that behavioral
therapy is generally not seen as effective as medication or combination therapy. Individual skills
development is facilitated by not necessary according to research therein cited. They also cite critique of the
conclusions of medication superiority by other researchers. Nevertheless, the majority of studies reviewed
noted the essential application of medication management for acute and moderate to severe cases of ADHD.
Owen and Hinshaw et al., (2003) provide an insightful extension to the MTA by asking which of the MTA
components (medications, behavioral management interventions, combinations, community support)
provides best functional and symptom improvement for which segment of the population under which
conditions. Of the numerous pieces, one most salient is that behavioral interventions including parent
training and therapy with medications were significantly more effective in social skill acquisition as rated by
teachers. Behavioral treatment proved equal to medication in reduction of anxiety based ADHD
complications. Therefore, behavioral management, in particular, contingency management behavioral
interventions have strong evidence of being effective. Farmer also notes that case management is effective
and the combination of child focused and family focused interventions are most effective. Social skill training
was supported also.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 17 of 22
BHS Treatment Guidelines for ADHD

Brief Therapy Models and ADHD: No brief therapy models were noted. The MTA did titrate the BEH over
the 28 days and therefore one could think that some of the component, particularly the parent training fell
within the less than 20 sessions.

Professional Status in Brief Therapy: Behavioral management can be supported by trained individuals
and educators. Much of the school based protocol and work is organized and conducted by educators instead
of credentialed mental health workers. Diagnosis must be made by a credentialed professional and not by
school workers or teachers. Case management and parent trainers could be trained with the curricula,
information and application of behavioral management principles to be effective.

Structure of most (Brief) Therapy: Individual teachers, parent. Some parent training in groups

Multi-Cultural Considerations: The literature on multi-cultural adaptation of evidence based treatments

was less than complimentary. Nagayama Hall, 2001, reviewing the empirically supported literature plainly
states: “there is not adequate empirical evidence that any of these empirically support therapies is effective
with ethnic minority populations” (p.502). Bernal and Scharron-Del-Rio, (2001) earlier noted the same
conclusion and called for a more “pluralistic” methodology in developing evidence based and culturally
sensitive treatments. The interpretation of impulsivity, attention and disruption are surely culturally bound.
While there is not any specific literature that arose in this brief summary, the definition of ADHD being
disruptive in at least two circumstances would cast cultural interpretation and assessment in a stronger light.
Arnold, Elliiott and Sachs et al, (2003) note that minority children need more behavioral therapy and
respond to combination treatment.

Pharmacological Interventions: Rivas-Vazquez et al, (2003) reviewed the use of Stratter for ADHD. He
concludes that it is safe and effective for children, adolescents and adults with ADHD symptoms. He also
notes that it lacks the street value of some stimulant medications. Methylphenidate, Concerta and other
stimulant medications remain the mainstays for medication management (Brown, 2002; NationaL Guideline
2002). Other drugs used are Wellbutrin, some tricyclics. SSRI have not shown efficacy in targeting the
main symptoms.

Manuals: None

Literature Summary References Used:

Arnold, L. E ; Elliott, M ; Sachs, L ; et al., Effects of ethnicity on treatment attendance, stimulant

response/dose, and 14-month outcome in ADHD. Journal of Consulting & Clinical Psychology. 71(4), Aug
2003, 713-727.

Bernal, G., Scharron-Del-Rio, M., Are Empirically Supported Treatment Valid for Ethnic Minorities? Toward An
Alternative Approach for Treatment Research. Cultural Diversity and Ethnic Minority Psychology, Nov 2001,
Vol. 7, No. 4, 328-342

Brown, RT.; La Rosa, A., Recent developments in the pharmacotherapy of attention-deficit/hyperactivity

disorder (ADHD).
Professional Psychology: Research & Practice. 33(6), Dec 2002, 591-595.

Farmer, EM. Z.; Compton, S N.; Burns, J. B; Robertson, E, Review of the evidence base for treatment of
childhood psychopathology: Externalizing disorders Journal of Consulting & Clinical Psychology. 70(6), Dec
2002, 1267-1302.

Nagayama Hall, GC. Psychotherapy Research with Ethnic Minorities Empirical , Ethical and Conceptual
Issues. Journal of Consulting and Clinical Psychology, June 2001, Vol. 69, No. 3, 502-510

National Guideline: Practice parameter for the use of stimulant medication in the treatment children,
adolescents and adults. 2002

Owens, E B.; Hinshaw, S P.; Kraemer, HC., et al., Which treatment for whom for ADHD? Moderators of
treatment response in the MTA. Journal of Consulting & Clinical Psychology. 71(3), Jun 2003, 540-552.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 18 of 22
BHS Treatment Guidelines for ADHD

Rivas-Vazquez, Rafael A. Atomoxetine: A Selective Norepinephrine Reuptake Inhibitor for the Treatment of
Attention-Deficit/Hyperactivity Disorder
Professional Psychology: Research & Practice. 34(6), Dec 2003, 666-669.

Root, R W. II; Resnick, R J., An update on the diagnosis and treatment of attention-deficit/hyperactivity
disorder in children Professional Psychology: Research & Practice. 34(1), Feb 2003, 34-41.

The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-
deficit/hyperactivity disorder. Arch Gen Psychiatry 1999 Dec;56:1073–86

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 19 of 22
BHS Treatment Guidelines for ADHD

Appendix C: Sample Treatment Plans

Treatment Plan for Attention Deficit / Hyperactivity Disorder (ADHD)
Problem #1:
ADHD

As evidenced by:
! Short attention span; difficulty sustaining attention on a consistent basis
! Susceptibility to distraction by extraneous stimuli
! Impression that the customer is not listening well
! Repeated failure to follow through on instructions, or complete school assignments, chores, or job
responsibilities in a timely manner
! Poor organizational skills as demonstrated by forgetfulness, inattention to details, and losing things
necessary for tasks
! Hyperactivity as evidenced by high energy level, restlessness, difficulty sitting still, or loud or excessive
talking
! Impulsivity as evidenced by difficulty awaiting his/her turn in group situations, blurting our answers to
questions before the questions have been completed, and frequent intrusions into others personal
business
! Frequent disruptive, aggressive, or negative attention-seeking behaviors
! Tendency to engage in careless or potentially dangerous activities from ___ % participation to ___ %
participation
! Difficulty accepting responsibility for actions, projecting blame for problems onto others, and failing to
learn from experience
! Low self-esteem and poor social skills

Goals:
1. Sustain attention and concentration for consistently longer periods of time from __ minutes to __
minutes
2. Increase the frequency of n-task behaviors as manifested by regular completion of school assignments,
chores, and work responsibilities from ____ # assignments completed to ___ # assignments completed
3. Demonstrated marked improvement in impulse control as evidenced by a significant reduction in
aggressive, disruptive, and negative attention seeking behaviors from ___ # altercations per week to
___ # altercations per week
4. Regularly take medication as prescribed to decrease impulsivity, hyperactivity, and distractibility.
5. The parents and/or teachers successfully utilize reward system, contingency contract, or token economy
to reinforce positive behaviors and deter negative behaviors.
6. The parents set firm, consistent limits and maintain appropriate parent-child boundaries.
7. Improve self esteem as evidenced by an increase in positive self-statements nd participation in
extracurricular activities.
8. Maintain lasting peer friendships
9. Maintain relationships with spouse and family members
10. Demonstrate patience, empathy and appropriate limit setting in roles as parent.

Objectives:
1. Increase participation in extracurricular activities or positive peer group activities.
2. Decrease the motor activity as evidenced by the ability to sit still for longer periods of time.
3. Teachers, spouse and/or supervisors reinforce on-task behaviors, completion of school assignments, and
good impulse control.
4. Teachers spouse and/or supervisors schedule breaks between intensive instructional periods and
alternate complex activities with less stressful activities to sustain the customer’s interest and attention.
5. The parents set firm limits and use natural, logical consequences to deter the customer’s impulsive
behaviors.
6. Increase the frequency of customer’s positive self-statements.
7. Decrease the frequency of arguments and physical fights with his/her siblings, other family members
and/or co-workers.
8. Increase verbalization by the customer in which he/she accepts responsibility for misbehavior.
This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 20 of 22
BHS Treatment Guidelines for ADHD

9. Reduce the frequency and severity of temper outbursts, acting-out, and aggressive behaviors.
10. Complete psychological testing to rule out emotional factors or learning disabilities as the basis for
maladaptive behavior.
11. Increase positive interactions with peers.
12. Establish a routine schedule to help complete homework, chores, and household responsibilities.
13. The parents identify and utilize a variety of effective reinforces to increase the customer’s positive
behaviors.
14. Teachers utilize a listening buddy who sits next to the customer in the classroom to quietly answer
questions or repeat instructions.
15. The parents maintain communication with the school to increase the customer’s compliance with
completion of school assignments.
16. The parents and teachers reduce extraneous stimuli as much as possible when giving directions to the
customer.
17. Complete psychological testing to confirm the diagnosis of ADHD.
18. Increase on-task behaviors as evidenced by greater completion of school assignments, chores and work
responsibilities.
19. Begin to take prescribed medication as directed by the physician.
20. The customer and his/her parents comply with the implementation of a reward system or contingency
contract.
21. The parents increase praise and positive verbalizations toward the customer.
22. The parents develop and utilize an organized system to keep track of shool assignments, chores, and
work responsibilities.

Therapeutic Interventions:
1. Encourage the customer’s parents or spouse to participate in an ADHD support group.
2. Encourage the parents to utilize natural, logical consequences for the customer’s disruptive and negative
attention-seeking behaviors.
3. Identify and reinforce positive behaviors to assist the customer in establishing and maintaining
friendships.
4. Encourage the customer to participate in extracurricular or positive peer group activities to improve
his/her social skills.
5. Arrange for the customer to attend group therapy to build social skills.
6. Encourage the customer to use self-monitoring checklists to improve attention, work or academic
performance and social skills.
7. Conduct family therapy sessions to assist the parents in establishing clearly identified rules and
boundaries.
8. Design a reward system and/or contract to reinforce desired positive behaviors and deter impulsive
behaviors.
9. Arrange for appropriate follow-up (i.e. appointment with psychiatrist, pediatrics or family medicine)
10. Design a behavior modification program for the classroom or workspace to improve the customer’s
academic or work performance, social skills, and impulse control.
11. Assign the customer’s parents to read 1-2-3 Magic (Phelan) and process the reading with the therapist.
12. Assist the parents or adult customer, in developing a routine schedule to increase the customer’s
compliance with school, household or work related responsibilities.
13. Identify a variety of positive reinforcers or rewards to maintain the customer’s interest or motivation.
14. Educate the customer’s parents and siblings about the symptoms of ADHD.
15. Teach the customer effective problem-solving skills (i.e. identify the problem, brainstorm alternative
solutions, select an option, implement a course of action, and evaluate.)
16. Monitor the customer for compliance, side-effects, and overall effectiveness of the medication. Consult
with the prescribing physician at regular intervals.
17. Arrange for medication evaluation for the customer.
18. Assist the parents in developing and implementing an organizational system to increase the customer’s
on-task behaviors and completion of school assignments, chores, or work responsibilities. (i.e. use of
calendars, charts, notebooks, and class syllabus.)
19. Instruct the parents on how to give proper directions (i.e. gain the customer’s attention, make one
request at a time, clear away distractions, repeat instructions, and obtain frequent feedback from the
customer.)
20. Teach the customer more effective test-taking strategies (i.e. study over an extended period of time,
review material regularly, read directions twice, recheck work.)
This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 21 of 22
BHS Treatment Guidelines for ADHD

21. Consult with his/her teachers to implement strategies to improve the customer’s school performance
(i.e. sit in front of the class, use a prearranged signal to redirect the customer back to the task, provide
frequent feedback, call on the customer often, arrange for listening buddy.)
22. Teach the customer more effective study skills (i.e. clear away distractions, study in quite places, outline
or underline important details use a tape recorder, schedule breaks in studying.)
23. Encourage the parents and teachers to maintain regular communication about the customer’s academic,
behavioral, emotional, and social progress.
24. Teach the customer self-control strategies (i.e. “stop, look, listen, and think”) to delay gratification and
inhibit impulses.

This guideline is design/ned for general use for most patents but may need to
be adapted to meet the special needs of a specific patient as determined by
the patient’s provider.
Page 22 of 22