Treatment of ADHD can be complex and multifaceted, requiring a clinical team that provides comprehensive care for patients and their families across the lifespan. The WV ACC Guidelines will aid clinicians in evaluating, diagnosing, and treating patients presenting with symptoms of ADHD and managing their ongoing care.
The WV ACC Guidelines includes a broad range of topics relating to ADHD including, but not limited to, evidence-based evaluation tools and recommendations, treatment modalities (nonpharmacological and pharmacological), and monitoring and follow-up recommendations. These recommendations are based on review and consolidation of national and international clinical practice guidelines, practice parameters, and clinical experience. It is intended to guide evaluation, diagnosis, treatment, and monitoring of low- and moderate-complexity patients and treatment of high-complexity patients while awaiting specialist care. The WV ACC Guidelines are not intended to replace adequate education and continuing education for ADHD, but rather to enhance an existing knowledge base.
Review of prescribing data indicates some regions of the state have high rates of stimulant prescribing. It is currently unclear whether these high rates are due to clusters of high ADHD prevalence, or higher rates of off-label stimulant prescribing. Individual clinicians should ensure, and document appropriately, that each patient being treated pharmacologically for ADHD has a complete diagnostic evaluation. Furthermore, clinicians should consider alternate and comorbid diagnosis in patients who do not improve clinically on stimulant medications.
Examples of Resources available (see full document and appendix for all available):
- Screening and assessment tools for ADHD and related conditions
- Overlapping symptom and distinguishing factors chart for other common comorbid conditions and/or alternative diagnoses
- Diagnostic flow chart
- Nonpharmacological treatment recommendations with evidence for use
- Common school accommodations and interventions
- Pharmacological treatment recommendations and resources
- Prescription stimulant conversion aid
- Monitoring and follow-up recommendations
- Risk reduction tools when prescription stimulants are used as treatment
This clinical practice guideline provides recommendations only. It does not replace clinical judgment and individualized, patient-centered decision-making.
| The WV ACC Guideline IS: | The WV ACC Guideline IS NOT: |
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Intended to encourage a multidisciplinary approach to evaluation, diagnosis, and treatment of ADHD and other comorbid concerns. |
Intended to replace adequate education and continuing education for ADHD. |
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An additional resource for those involved in the comprehensive care of patients with ADHD. |
Endorse or recommend the use of any particular drug. |
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Intended to aid with individualized patient-centered care by providing evidence-based recommendations while also considering patient-specific factors. |
Intended to address all possible diagnosis methods, treatments, follow up, drugs or their related contraindications or side effects. |
West Virginia has been identified as having a significantly higher prevalence of ADHD in children aged three to 17 years of age than the national average, 13.2% versus 8.6%, respectively, in the 2019 National Survey of Children’s Health (NSCH) (DRC, 2019). The state has a corresponding shortage of behavioral health services due to its rural landscape. Of the state’s 55 counties, 44 are rural, and many patients lack transportation or can face long travel to access care. (Rural Health Information Hub,2022). Telemedicine offers a viable method of providing additional access, but limited interactions with clinicians can lead to misdiagnosis and insufficient monitoring, and limited access to broadband internet further exacerbates accessibility issues.
Further factors contribute to West Virginia’s disparity of care. The state’s higher poverty rates and lower number of specialized mental health professionals contribute to health inequities. There is also a suspected correlation between the increased prevalence of ADHD and the high rates of maternal substance use present in West Virginia. Additionally, the Appalachian culture in the state also presents challenges for clinicians when treating patients due to their lack of trust in medical professionals. Therefore, there is a need to increase access to evidence-based, effective treatment through outreach and training for clinicians and other individuals involved in the care of patients with ADHD in West Virginia.
ADHD is a neurodevelopmental disorder characterized by developmentally inappropriate levels of inattention, hyperactivity, and/or impulsivity, which impair an individual’s ability to function in different settings (Magnus et al., 2023). ADHD is closely linked to early brain development and believed to be caused by an imbalance of catecholamines (norepinephrine, dopamine, and epinephrine). Genetics can be a risk factor for the development of ADHD, and the heritability of ADHD has been estimated to be 76% to 80% (Bukstein, 2022; Fliers et al., 2005).
Various environmental exposures, both prenatal and postnatal, may influence the development of ADHD. Some of these risk factors include Adverse Childhood Experiences (ACEs), prenatal substance exposure (acetaminophen, nicotine, alcohol, and illicit substances), and other secondary causes. ACEs are potentially traumatic events that happen before adulthood, and specifically in West Virginia, 55.8% of adults reported to have at least one ACE (WVDHHR, 2018). Another risk factor identified in recent studies is a possible correlation between in utero acetaminophen exposure and an increase in the risk of development of ADHD (Alemany et al., 2021). In utero substance exposure is another significant risk factor for developing ADHD, and nearly one in eight infants born in West Virginia were exposed to opioids, stimulants, and/or cannabis in utero (Umer et al., 2023). Further, secondary causes of ADHD, like traumatic brain injuries, toxic metal exposure, and infections, are not well studied, but awareness of these risk factors can aid in evaluation, diagnosis, and treatment. Prevention and early intervention are crucial for improving the mental and physical health of children and adults in West Virginia.
Primary care clinicians play a crucial role in identifying ADHD in both children and adults, but not all clinicians feel prepared to diagnose or treat ADHD. It has been shown that many individuals are receiving treatment for ADHD without a corresponding diagnosis. For example, 38% of children and 55%-66% of adults treated with stimulants do not have a corresponding ADHD diagnosis (Sibley 2018). Therefore, clinicians should conduct a thorough and comprehensive evaluation to ensure an accurate diagnosis.
The American Academy of Pediatrics (AAP) recommends that for patients between the ages of four and 18 years, a pediatrician or primary care clinician initiate an evaluation and treatment for ADHD and other coexisting conditions, and the American Academy of Family Physicians (AAFP 2023), also recommend a comprehensive evaluation for adults presenting with symptoms of ADHD. (Wolraich et al., 2019). A comprehensive evaluation for ADHD may include a physical exam, multiple visits, clinician observation, symptom comparison to DSM-5-TR criteria, a bio-psycho-social assessment, broadband and narrowband assessments, and clinical interviews. It is also imperative during the comprehensive evaluation to consider the possibility of a coexisting condition or even an alternate diagnosis as the cause of symptoms.
Nearly two-thirds of children with ADHD have at least one coexisting condition (Danielson et al., 2018), and approximately 60% to 70% of adults have a coexisting condition (Piñeiro-Dieguez et al., 2016). Common comorbidities and/or alternative diagnoses can include anxiety disorders, depressive disorders, bipolar disorders, autism spectrum disorder, trauma and stressor-related disorders, learning disorders, oppositional defiant disorder, intellectual disabilities, substance use, and sleep disorders. ADHD is a diagnosis of exclusion for which screening and assessment tools can assist in the diagnostic process. Clinicians should consider alternative diagnoses and coexisting conditions to avoid incorrect diagnoses or missed coexisting conditions. Failure to adequately treat ADHD symptoms in addition to any other coexisting conditions can lead to significant impairment in daily life, including academic achievement, daily responsibilities, and employment expectations.
Although ADHD often persists into adulthood, symptomology may change as the patient ages. For example, younger children (especially males) are more likely to demonstrate and be diagnosed with the hyperactive/impulsive presentation of ADHD than older children. While some symptoms decrease with age, others may increase. Adult patients report higher levels of inattention as they age.
As symptoms change throughout a patient’s lifespan, treatment may also need to be adjusted to optimize symptom control and improve patient outcomes. For example, the AAP does not recommend making a diagnosis of ADHD in children less than 4 years of age, and evidence-based behavioral therapies are considered first-line treatment. As a patient ages, the evidence-based nonpharmacological treatments may need to be adjusted based on the patient’s developmental stages, and medication may be incorporated at later stages of life. Additional considerations to ensure optimal patient outcomes are to support patients and adjust treatments during life transitions such as children entering the school setting, adolescents transitioning to adulthood, and adults entering the workplace. Listed below are the age-appropriate, evidence-based treatment recommendations for ADHD throughout a patient’s lifespan.
*Of note, the AAP advises to avoid a diagnosis of ADHD prior to the age of four years.
Non-pharmacological interventions for ADHD include various approaches such as Behavioral Parent Management Training (BPMT), peer interventions, cognitive behavioral therapy, cognitive behavioral training, combined behavioral management interventions, and combined training interventions. Modified BPMT, organizational skills training, psychological counseling, emotional therapy, social skills training, and technological aids are also possible interventions.
Nonpharmacological, evidenced-based behavioral interventions are recommended as first-line treatment for preschool and school-aged children, and to augment pharmacological interventions in adolescents. Children utilizing nonpharmacological interventions early were more likely to delay pharmacological treatment or avoid it altogether (DuPaul & Kern, 2011). For adults with ADHD, some behavioral approaches such as cognitive behavior therapy can be used in conjunction with medication to improve symptom control. Clinicians should consider and implement age-appropriate, evidence-based nonpharmacological treatments, where available, into a patient’s treatment plan to optimize ADHD symptom control.
Further details regarding nonpharmacological treatment options and their corresponding evidence for use in the treatment of ADHD can be found here.
A comprehensive treatment plan for ADHD medication is crucial, and it should incorporate patient-specific considerations. These considerations include age, patient/family preference, previously successful/failed trialed medications (considering the patient and family’s history of medication responses), routes of administration, comorbidities, and side effects, should be accounted for when determining the optimal treatment plan inclusive of a pharmacological option. Ensuring a patient meets criteria for ADHD is important when considering to initiate a medication. Further, patient and caregiver education, selection of a medication according to patient-specific factors, and considerations for closely monitoring and adjusting the dosage are necessary when utilizing pharmacological agents for treatment of ADHD.
Prescription stimulants are the first-line treatment in patients 6 years of age and older who have been determined to be a candidate for stimulant therapy, and these medications should be prescribed in addition to age-appropriate behavioral therapies. In patients 6 years of age and older, long-acting formulations are preferred due to their longer duration of symptom control, increased likelihood of monotherapy, and improved adherence (Pohl et al., 2009) (SAMHSA, 2015). If stimulants are prescribed, regular monitoring of height and weight should be implemented.
Prescription stimulants are not the only pharmacological treatment option for ADHD. There are also other FDA-approved medications available for treatment of ADHD, including norepinephrine reuptake inhibitors and alpha-2 agonists. In fact, atomoxetine, a norepinephrine reuptake inhibitor, is recommended as first-line therapy in adults and can be utilized in patients greater than 6 years of age who are not candidates for stimulant therapy. There are other medications which do not have an FDA-approved indication for the treatment of ADHD that may be appropriate for certain patients, such as those with coexisting conditions. However, less documented safety and efficacy data is available, and off-label use of these medications should only be done at the careful discretion of the clinician, who either has specialized training or is referring the patient for specialized care.
Close monitoring and follow-up are essential to evaluate a patient’s treatment plan for effectiveness, safety, and adverse effects, especially when inclusive of a medication. The AAP and AAFP recommend follow-up every 30 days until ADHD symptoms improve and then every 3 to 6 months thereafter (AAFP, 2023a; Wolraich et al., 2019). When prescription stimulants are prescribed, it is necessary to monitor for signs of misuse and diversion.
1.8%, or approximately 5.1 million, of the United States (U.S.) population aged 12 years and older misused prescription stimulants in 2020, and 0.3%, or approximately 758,000 people, had a prescription stimulant use disorder (National Institute on Drug Abuse [NIDA], 2020). 23.4% of youth (12-17 years) who had utilized any prescription stimulant in the last year reported misuse. For young adults (18-25 years) who had utilized any prescription stimulant in the last year, that number increases to 45.2% (Safer, 2015). However, when used as prescribed for a legitimate medical purpose, there is an abundance of evidence to show that prescription stimulants can effectively reduce the symptoms and the negative impacts of ADHD.
To prevent misuse and mitigate risks of diversion, clinicians should implement risk reduction strategies at their discretion. Risk reduction strategies for safer stimulant use can include risk screening tools, urine drug screening/testing, patient-provider agreements, and routine checking of the Prescription Drug Monitoring Programs (PDMP). Per West Virginia code, prescribers much check the PDMP, or Controlled Substance Monitoring Program (CSMP), initially when prescribing a Schedule II, III, IV, V controlled substance and at least annually thereafter. It is best practice to verify patient fill history through the CSMP/PDMP when a new prescription is provided, or at least every 3 months.
The CDC reports that one in 100 women take ADHD medication while pregnant. Limited safety data exists for using ADHD medication during pregnancy, and it may be associated with birth defects. While the benefits of using medication may outweigh the risks in severe cases, fetal risk cannot be ruled out. Likewise, preterm birth and low birth rate have been significantly associated with stimulant exposure. Clinicians should have an open discussion with patients who are pregnant or planning to become pregnant to determine the best course of therapy.
The ability to breastfeed is another area of concern for clinicians of women with ADHD. While limited information is available, ADHD medications have been shown to be present in breast milk. For breastfeeding mothers, some ADHD medication can reduce milk supply, but neurological development of exposed infants has not been studied. For further information regarding ADHD medications and use during breastfeeding, please click here.
Complementary and Integrative Medicine (CIM) is a non-mainstream approach used alongside conventional medical treatments. Unfortunately, it is common that CIM is either not studied for safety and efficacy, can be unsafe or not effective for treatment of ADHD, or a combination. However, patients may attempt to utilize CIM to improve overall health and quality of life, avoid potential side effects of medications, complement traditional therapies, and treat symptoms. Therefore, clinicians should be prepared to counsel patients on the safety and effectiveness of proposed CIM treatments, monitor the response to treatment, identify drug interactions, and reevaluate if there is no response or harm.
Further information regarding commonly attempted CIM for ADHD can be found here in addition to strategies for discussing CIM with patients.
References
General disclaimer:
This content is not intended to address all possible diagnosis methods, treatments, follow up, drugs or their related contraindications or side effects. Standards of practice change as new data becomes available. Therefore, it is strongly recommended that practitioners independently assess and verify diagnosis, treatments and drugs for each individual patient. The authors of the WV ACC guidelines assume no liability for any aspect of treatment administered by a practitioner with the aid of this publication.
Drug disclaimer:
The authors do not endorse or recommend the use of any particular drug mentioned in this publication. Before prescribing a new drug to a patient, practitioners are advised to check the product information accompanying each drug to ensure it is appropriate for a specific patient and to identify appropriate dosage, contraindications, side effects and drug-to-drug interactions.
Standard of care disclaimer:
This publication is not intended to establish a standard of care applicable to practitioners who treated patients diagnosed with ADHD. “Standard of care” is a legal term, not a medical term, which refers to the degree of care a reasonable practitioner would exercise under the same or similar circumstances. The standard of care is a continuum and does not imply optimal care. Practitioner discretion and clinical judgment are paramount and this publication is only intended to aid practitioners’ judgment, not to serve as a substitute for said judgment.