Care Process Model

DECEMBER 2016

MANAGEMENT OF

Attention Deficit Hyperactivity

Disorder (ADHD) — 2016 update
Intermountain Healthcare continues to work toward developing and refining processes and tools to improve management of
ADHD. This care process model (CPM) and accompanying tools (forms, data, patient education) were developed in cooperation
with several other organizations, including the Intermountain Pediatric Society, the American Academy of Pediatrics Utah Chapter,
and Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD) of Utah.

Why Focus ON ADHD? WHAT’S INSIDE?

• High prevalence. ADHD is one of the most common chronic childhood OVERVIEW. . . . . . . . . . . . . . . . . . . . . 2
disorders, and often persists into adulthood. Current CDC estimates indicate
EVALUATION AND DIAGNOSIS. . . . . 4
that the prevalence of ADHD has increased from 2003 to 2007, with
approximately 9.5% of all children and teenagers diagnosed with the disorder TREATMENT PLAN OVERVIEW . . . . . 6
and rates as high as 13.8% for teenagers age 15 to 17. CDC The prevalence of adult
MEDICATION MANAGEMENT. . . . . . 8
ADHD is estimated at 4%, according to a national comorbidity survey. KES
PATIENT AND FAMILY EDUCATION. . 14
• Need to screen for and treat comorbidities. Complicating the assessment
and treatment of ADHD is the fact that at least 1/3 of children have one or more SUMMARY OF INTERMOUNTAIN
coexisting conditions that may affect treatment decisions. PLI1 A Mental Health RESOURCES. . . . . . . . . . . . . . . . . . . 13
Integration (MHI) care team can support and guide choices that are effective in WORKING WITH SCHOOLS . . . . . . . 14
treating specific comorbidities.
REFERENCES . . . . . . . . . . . . . . . . . . 16
• Long-term consequences for patients. Children with ADHD who don’t
receive appropriate treatment may be at increased risk for substance abuse,
teenage pregnancy, complex learning difficulties, school problems, and even GOALS & MEASURES
criminal behavior as they move into adolescence and beyond. BAR1,CDC The goals of this CPM are to:
• Assist primary care physicians in identifying
• Challenge of managing parental and public expectations. Physicians must
and treating ADHD and comorbidities in
cope with intense pressure from parents presenting their child’s case as a crisis children and adults
situation — pushing physicians to act with immediacy, rather than deliberation.
• Encourage use of evidence-based tools
Also, public scrutiny of treatment with psychotropic medications can contribute throughout healthcare and school systems
to uncertainty for families about the best course of medical treatment.
• Support education of patients and families,
• Need for communication and collaboration between physicians, family including strategies to deal with ADHD’s effects
members, and school staff. Lack of ongoing continuity and consistency
can severely impact outcomes for the child or adolescent patient. This CPM Intermountain measures:
provides tools to help physicians communicate and collaborate with patients, • Patients age 6 to 12 with a prescription for
parents, and schools to plan treatment, set goals, and follow up on progress. ADHD medication who had a follow-up visit
during the 30-day initiation phase.
• Patients age 6 to 12 with a prescription for
What’s new IN THIS UPDATE? ADHD medication who had at least two
follow-up visits with a practitioner within
(2016 update indicated in bold type below)
9 months after the end of the initiation phase.
• Intermountain measures (at right)
• DSM-5 updates (page 2)
• New Substance Use Disorder screening tool (page 5)
• 2016 medication updates (pages 10 - 13)
• A new tool to help parents, clinics, and schools collaborate to address children’s mental
health problems using the MHI process (page 14 — sidebar)
M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D) DECEMBER 2016
ADHD DIAGNOSTIC CRITERIA:
DSM-5 UPDATES
The definition of ADHD has been
updated in the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5)
to more accurately characterize the
experience of affected adults. DSM Refer
to the DSM-5 for details. In 2015,
Intermountain‑employed physicians
will be able to access an online version
of the DSM-5 through the eResources
page on IntermountainPhysician.org.
2 ©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
OVERVIEW
The recommendations in this CPM — and the tools that support them — constitute
a pragmatic approach to a complex problem. They are based on several core principles:
• The treatment of ADHD is a collaborative process, which must actively involve the
patient’s family as well as school staff and medical personnel.
• ADHD must be viewed from a holistic perspective, considering comorbid
conditions that may contribute to dysfunction.
• The goal of treatment is to improve day-to-day functioning in previously identified
areas of impairment, not merely to suppress ADHD symptoms.
This care process model aligns with the recommendations of the American Academy
of Pediatrics (AAP) for the diagnosis and treatment of school-aged children A AP1,AAP2
and the 2007 practice parameter established by the American Academy of Child and
Adolescent Psychiatry (AACAP) for assessing and treating children and adolescents. PLI1
Diagnosis in children
See pages 4 through 5 for details on diagnosis; key points appear below.
• The primary care physician should initiate the ADHD evaluation for all children who
present with inattention, hyperactivity, impulsivity, academic underachievement,
or behavior problems. ADHD screening should also be included when a patient
undergoes other types of mental health assessment.
• Diagnosis of ADHD requires meeting criteria set forth in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5). DSM
• The assessment requires evidence directly obtained from parents or caregivers and
from the classroom teacher (or other school professional) regarding core symptoms
of ADHD in various settings, the age of onset, duration of symptoms, and degree of
functional impairment.
• Evaluation should include assessment for psychiatric comorbidities.
• Before diagnosing ADHD, disorders that can mimic ADHD should be excluded.
• ADHD is established using the methods above; other diagnostic tests (such as
SPECT scan or EEG) are not routinely indicated.
Treatment in children
See pages 6 through 9 for details on treatment; key points appear below.
• Treatment programs should recognize ADHD as a chronic condition.
• The treating clinician, parents, and child — in collaboration with school
personnel — should specify appropriate goals to guide management.
• Stimulant medication has been shown to be the most effective treatment for patients
with ADHD and should be used when appropriate to improve target outcomes in
children with ADHD. Where comorbid conditions exist, behavioral therapy (if
appropriate) should be recommended.
• When the selected management for a child with ADHD has not met target
outcomes, clinicians should re-evaluate the original diagnosis, use of all appropriate
treatments, adherence to the treatment plan, and presence of coexisting conditions.
• The clinician should periodically provide systematic follow up. Monitoring should
be directed to the child’s individual goals and any adverse effects of treatment, with
information gathered from parents, teachers, and the child.
DECEMBER 2016 M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D)

Diagnosis and treatment in adolescents and adults TEENAGE DRIVING RISKS

• Adolescents: Impairment in middle school and high school can have significant ADHD can cause additional risks for teenage
drivers. Teenagers and young adults with
consequences and presents additional risks for teenage drivers (see sidebar). The
ADHD are more likely to drive a car without
following are a few considerations to keep in mind for evaluating and treating a license, have their licenses suspended or
adolescent patients: revoked, have crashes, and be at fault for these
–– Adolescent patients diagnosed in childhood: The initial symptoms that prompted crashes. 
BAR2,KES
A study with a large sample
treatment (restlessness, interrupting, difficulty waiting in line) can fade in adolescence. of ADHD patients followed into adolescence
However, be cautious about discontinuing treatment. ADHD persists into adolescence and adulthood — and demographically
in as many as 85% of patients UPA and also persists into adulthood in as many as 60% of similar controls without ADHD — suggests an
patients (see below for advice on diagnosis and treatment of adults). increased risk of potentially dangerous driving
THO
outcomes for the ADHD patients. 
–– Patients evaluated in adolescence: Adolescents being evaluated for depression or
anxiety should be assessed for ADHD as well. You may also see patients who have been
able to cope with elementary school despite ADHD symptoms, but request help when
SCREENING AND DIAGNOSIS
faced with increased demands for focus and organization in middle school or high OF ADULT ADHD
school. At this age, the proportion of girls with ADHD can increase. Adult ADHD often presents itself differently
–– Diagnosis and treatment: As with pediatric patients, use the diagnosis, treatment, than childhood ADHD: GOO
and medication management algorithms on pages 4 through 9. Frequent monitoring of • Adult ADHD frequently has one or more
of these core features: inattention,
medication is critical, as stimulants have a higher potential for misuse or diversion in the distractibility, impulsiveness, poor
middle school or high school environment. concentration, inability to persist at tasks,
difficulties with working memory, and
• Adults: Up to 60% of childhood ADHD cases persist into adulthood. Often, the difficulties with organization and planning.
hyperactive symptoms of childhood resolve, leaving symptoms related to executive • Adults may not recall early symptoms;
function that can impair daily functioning and work performance (see sidebar). diagnosis of adult ADHD does not require
–– Diagnosis: Adults often realize that they may have ADHD when their child is formal diagnosis in childhood.
diagnosed. However, the American Academy of Pediatrics (AAP) diagnosis guidelines • The male-female ratio for adult patients with
and many diagnostic tools are focused on children. If you or your adult patients suspect ADHD is different than that for children; the
male-female ratio drops to 3:2, and women
ADHD, use the ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist provided in the are often more impaired than men.
MHI Adult Baseline Packet (see sidebar). Confirm the diagnosis through consultation To screen for ADHD, use the ADHD
with a mental health professional. Diagnosis of adult ADHD does not require formal Self‑Report Scale (ASRS-v1.1) Mental Health Integration Child/Adolescent

diagnosis during childhood; research indicates symptom onset before age 7 is not a key
ADHD Patient Management Plan (page 1 of 2)

Patient’s Name: Diagnosis: Date:

Physician Name: Phone:

Symptom Checklist, developed

School Psychologist/Guidance Counselor: Phone:
Please use this form to guide your treatment and to help facilitate communication of goals and progress between you, your child’s doctor, and your
child’s teacher(s) and school psychologist/guidance counselor.
Make it fun! Child can color in, or place stickers
MEDICAL PLAN on, stars when each area is completed.
Medication: Medication: Medication: Other Appointments (color in stars)

factor in diagnosing adult ADHD, FAR1 and the DSM-5 revises age-of-onset criterion to
Date: Date: Date:  Specialist referral:
Time: am/pm Time: am/pm Time: am/pm Date:
Name:
Dose 1: mg Dose 1: mg Dose 1: mg
Date: Date: Date: Phone:

and validated by the World

 First follow-up appointment in 3-4 weeks.
Time: am/pm Time: am/pm Time: am/pm
Follow-up date:
Dose 2: mg Dose 2: mg Dose 2: mg Physician will review medication effects and side
effects and check progress toward goals. Bring
Date: Date: Date:
completed Child & Adolescent Follow-up
Time: am/pm Time: am/pm Time: am/pm Evaluation Packet and Follow-up School
Packet with you to your appointment.
Dose 3: mg Dose 3: mg Dose 3: mg (See Home Plan and School Plan below.)

Medication Instructions:  Other follow-up appointments:

Doctor may request follow-up appointments
1 Make sure your child takes medication as prescribed. Don’t allow your child to skip doses. Your child’s as often as every 3-4 weeks until child is stable
doctor will give you instructions for what to do if a dose is missed.

age 12 (was age 7 in DSM-IV) (see sidebar on previous page).

and shows progress toward goals. After that,
2 Watch for side effects. Your Child & Adolescent Follow-up Evaluation Packet has a 2-page “Child & follow-up visits are generally every 3-6 months.

Health Organization for adult

Adolescent Follow-up Consultation” form. The 2nd page lists possible side effects from medications Follow-up date:
used for ADHD and other mental health conditions. Use the form to help monitor your child’s reactions.
Call your child’s doctor immediately if any side effects concern you. Follow-up date:

HOME P L AN
PARENT TO DO LIST: Date completed
 Read the materials you received from our clinic and locate additional information on the web (ihc.com/adhd)
 Contact a parent support group (e.g., CHADD of Utah (main number 801-537-7878))
 Sign up for a parenting class

ADL
 Seek individual/family counseling

ADHD screening. 
 Other:
GOAL SETTING (see back for “IDEAS FOR SETTING AND MONITORING GOALS”)
Domain (area to work on) Goals (see back for ideas) Reward Goal met (color in stars)
 Home Behavior 1.

–– Treatment: Stimulants and, to a lesser degree, antidepressant medications with

(ability to follow home rules, 2.
Date:
parents’ commands, etc.) 3.
 Enterpersonal relationships 1.
(ability to form and maintain positive 2.
Date:
friend and family relationships) 3.
 Emotions 1.
(ability to express or control 2.
Date:
emotions) 3.

© 2013 World Health

 Home Responsibilities 1.
(ability to perform daily home 2.
Date:
responsibilities) 3.

©2004-2009 Intermountain Healthcare. All rights reserved.

IHCADD002 - 03/09

norepinephrine and / or dopamine stimulation actions are the standard of treatment. Organizations.
Dosages are comparable to dosages for children on an mg / kg basis. Sustained release Used with permission.
preparations may reduce the risk of chemical dependency.
To confirm a diagnosis of ADHD in adults,
consult with a mental health professional.
Psychiatric comorbidities
Since psych comorbidities are relatively common with ADHD, screening for these RESOURCES FOR ADULTS
conditions is vital. Identifying comorbidities can help physicians determine risk, assess Organizations:
the need for therapy, and choose the most effective medication.
• CHADD (Children and Adults with ADHD):
• The MHI Baseline Packet (Adult or Child & Adolescent) can help you identify comorbidities. chadd.org; (see also the
These packets include validated tools to screen for symptoms of several comorbidities. National Resource Center on ADHD:
• An MHI team can help you provide comprehensive evaluation and treatment. For help4adhd.org)
example, some medications may be more effective with certain ADHD / comorbidity • Attention Deficit Disorder Association
combinations. PLI2 A Mental Health Specialist can provide insight on medication and (ADDA): add.org
other treatment options. Community resources can also be very helpful. Books:
• Driven to Distraction: Recognizing and Coping
Substance use disorder (SUD) with Attention Deficit Disorder. Edward
Hallowell and John Ratey. Touchstone 2011.
• ADHD treatment in childhood can prevent SUD. Studies have shown that treating
• More Attention, Less Deficit: Success
ADHD in childhood with stimulant medication can help prevent SUD later on.  FAR2
Strategies for Adults with ADHD. Ari Tuckman.
• For adolescent and adult patients, family screening for SUD is critical. A significant Specialty Press / A.D.D. Warehouse 2009.
percentage of adolescents and adults with ADHD also have SUD. UPA Before treating a • Taking Charge of Adult ADHD. Russell
Barkley. Guilford Press 2010.
teen or adult with stimulants, consider screening both patient and family for SUD.
©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 3
M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D) DECEMBER 2016

THE KEY TO DIAGNOSIS ALGORITHM 1: EVALUATION AND DIAGNOSIS (a)

The key to diagnosis is evaluating
impairment. Determine whether the Routine Screening and / or Patient
child’s behavioral symptoms impair social,
academic, or occupational functioning. Family Requests Appointment (b)
Treatment is recommended based on this
impairment and its severity. Send / give Baseline
Evaluation Packets Can patient be
RESOURCES FOR DIAGNOSIS no seen within
to parents / schools to
1–2 weeks? (c)
Several resources — available at complete before visit
intermountainphysician.org/ (see sidebar) yes
clinicalprograms under the “Mental Health
Integration (MHI)” topic — can help you
evaluate and diagnose patients. 1ST OFFICE VISIT — Initial Evaluation (c)
• MHI Baseline Packets: 1. Perform medical history / physical exam (d).
–– Child & Adolescent Baseline 2. If you suspect ADHD and / or other psych comorbidities, give the parent a
Child & Adolescent Baseline Evaluation Packet to complete before next visit and a
Evaluation Packet includes a validated
School Baseline Evaluation Packet to take to the school psychologist or teacher(s) to
parent screening tool and home complete by next visit (see sidebar for tool description).
impairment scale
3. Explain to parent(s) that diagnosing ADHD depends on information from
–– School Baseline Evaluation Packet both parents and teachers.
includes a validated teacher screening 4. Instruct parent(s) to make a follow-up appointment when both packets are
tool and school impairment scale complete, preferably within the next 3 to 4 weeks.
For access to the Vanderbilt ADHD
screening tool, visit nichq.org/
childrens-health/adhd/resources/ Patient / Parent School
vanderbilt‑assessment‑scales
1. Complete the Baseline 1. Complete the School
• Scoring and Evaluating Evaluation Packet. Evaluation Packet.
MHI Forms (Adult and 2. Take School Evaluation Packet to 2. Administer any other tools the school
Child & Adolescent): child’s school psychologist / guidance feels would help in diagnosis or in
counselor, and arrange for a time to planning interventions.
Explains how to score
pick up forms. 3. Give a copy of the completed
the baseline packet and
evaluate risk, illustrated 3. Once both packets are complete, intervention tools to the parent to
make a follow-up appointment with take to the physician. Save a copy for
with case study examples.
the primary care provider. the school records.
• Stratification and Care Today’s Date:
Mental Health Integration
MHI Stratification and Care Plan: CHILD/ADOLESCENT
 Initial Eval  Follow-up Eval  Packet Review Only

Plan (Adult and Child

Patient’s Name: Date of Birth: MRN:
Clinic: PCP: Care Manager:

SCORE SUMMARY
Measure MILD MODERATE HIGH Target concerns/action
1. Reported concerns

EVALUATION / DIAGNOSIS VISIT

2. Previous mental health tx Previous tx:  meds  therapy  hospital
S 3. Somatic Medical comorbidities:
4. Chronic pain
& Consultation
Initial History

5. Sleep

& Adolescent): Is used

6. Medications
7. Family HX
8. Abuse/trauma
9. Alcohol/substance use
10. Environmental stressors # days missed:
11. Overall impairment Patient: Clinician: Patient: Clinician: Patient: Clinician:
12. Overall health Patient: Clinician: Patient: Clinician: Patient: Clinician:

(within 3 to 4 weeks of first office visit or receipt of packet)

Parental depression
O Family relational style

for initial diagnosis and

ADHD Symptoms
Vanderbilt Vanderbilt
Home Packet (HP) & School Packet (SP)

Parent

Performance
Comorbidities
Screening tools

ADHD Symptoms
Teacher

Performance
Comorbidities
Depression symptoms Suicide risk:  low  int  high
Anxiety/stress disorders
Developmental Disorders Impairment: Impairment: Impairment: >4 for any symptom is positive
Mood Disorders

treatment planning.
Home Impairment
School Impairment
DIAGNOSIS TIME SPENT:
A
Improvement Ratings: Home:  none  mild  mod  sig School / work:  none  mild  mod  sig
FOLLOW-UP ONLY :
Self-Management Progress:

1. Use MHI program resources to evaluate and “score” information in the packets before
COMP L EXITY AND SEVERITY STRATIF ICATION*
 MILD severity and complexity  MODERATE severity and complexity  HIGH severity and complexity
CARE P L AN (level of team management)*
P ROUTINE CARE (PCP; CM as needed) COLLABORATIVE CARE (PCP, CM, MHS) Consult with MENTAL HEALTH SPECIALIST
 Watchful waiting  Medication plan:  ED crisis evaluation  Suicide risk eval
 Medication plan:  Comorbidity plan:  MHS (PhD/MSW/Psychiatrist/APRN):
Other:  Care management  Consultation  Psychotherapy  CBT goals

seeing the patient (can be done by primary care provider or office staff).
 Psychotherapy  Medication plan:
 Care management (optional)
 Psychiatrist/APRN consult  Comorbidity plan:
  Substance abuse treatment  Other:
  Other:  Care management
All patients:  Substance abuse treatment
All patients:
 Education/self-management plan given All patients:
 Education/self-management plan given
 PCP follow-up appt:  Education/self-management plan given
 PCP follow-up appt:  PCP follow-up appt:
 Follow-up MHI Packet given  Follow-up MHI Packet given  Follow-up MHI Packet given
Consultation notes: *Determine treatment plan and level of team management based on DSM-IV
criteria, clinical judgment, and overall severity and complexity. Suicidality places
patient in the HIGH severity and complexity category. See the Primary Care

2. Perform medical history / physical exam if not already done in an initial evaluation (d).

Guide to Scoring and Evaluating Child & Adolescent MHI Forms.
©2004-2009 Intermountain Healthcare. All rights reserved.
IHCMHI004A - 11/09

3. Review packets, and interview patient / parent.

Meet diagnostic Discontinue ADHD algorithm; determine

no need for further evaluation. If appropriate,
criteria? (e)
consult with school psychologist.
yes
Based on level of risk (h),
yes activate MHI team or consider
Suspect comorbid mental health specialist referral.
conditions? (f, g)
no Initiate ADHD
Treatment Plan
(see page 6)

4 ©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .

DECEMBER 2016 M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D)

EVALUATION AND DIAGNOSIS ALGORITHM NOTES

(a) A focus on children and adolescents
This algorithm is primarily structured for diagnosis of ADHD in children
and adolescents. To diagnose adults, use the ADHD Self-Report
Scale Symptom Checklist (World Health Organization), FAR1 provided
in the MHI Adult Baseline Packet, and consult with a mental health
professional. See resource information on pages 15-16.
(b) Screening and/or appointment request
Some parents will request an appointment based on a child’s ADHD
symptoms, but other parents will not. Screening for ADHD during
routine health appointments can help in identifying and treating this
common disorder. Asking about concerns at school, work, or home
can reveal problems that indicate the need for further evaluation.
(g) Substance use disorder (SUD)
In adolescents and adults, SUD is common, particularly for patients
who also have conduct disorder. UPA To screen for SUD, interview the
patient (if an adolescent, preferably with parents not present) using:
• The CRAFFT tool for adolescents
• The Intermountain‑Modified National Instituted on Drug Abuse
Quick Screen NIDA questions below for adults
(See the Substance Use Disorder CPM for more information about using
these tools and next steps if patient screens positive.)
For adult patients, also consider checking the DOPL database.
Go to csd.utah.gov.
In the past year, how often have you used

Monthly
Once or

Daily or
Weekly

Almost
Never

Twice

Daily
the following?

(c) Timing of initial evaluation and Alcohol: •• For men, ≥5 standard drinks* a day
completion of packets •• For women, ≥4 standard drinks
a day
This algorithm presents one common flow of events that works for
many offices. Some offices may choose to send the Baseline Evaluation Tobacco products (including e-cigarettes)
Packet and the Baseline School Packet to the parent (or patient) before
the initial visit, especially if it will be several weeks before the initial Prescription medications for non-medical reasons
appointment.
Prescription medications in amounts greater
than prescribed, for reasons other than
(d) History and physical exam prescribed, or that weren’t prescribed to you
Illegal drugs (illicit, street drugs)
History and physical exam should include assessment of the
child’s developmental history, hearing and vision, any learning *Definition of a “standard drink:” •• Table wine (12% alcohol): 5 oz
difficulties or psychiatric illness, and family history of ADHD. •• Beer or wine cooler (5 % •• 80-proof spirits (hard liquor)
The MHI Child & Adolescent Baseline Packet includes an alcohol): 12 oz (40 % alcohol): 1.5 oz NIH
Initial History and Consultation form to help with this task. •• Malt liquor (7 % alcohol): 8 – 9 oz
For adult patients, consider checking the DOPL database.
Go to csd.utah.gov. (h) Risk assessment and level of complexity
(mild, moderate, or severe)
(e) Diagnostic criteria Risk assessment and level of complexity (mild, moderate, or
severe) is based on evaluating coexisting conditions, family coping style,
Refer to the DSM-5 for details on updated diagnostic criteria for
 DSM
level of impairment, history of mental/behavioral disorders, and other
ADHD. In 2015, Intermountain-employed physicians will be able to factors. See Scoring and Evaluating Child & Adolescent MHI Forms for
access an online version of the DSM-5 through the eResources page more information on assessing risk. For patients with a moderate risk
on IntermountainPhysician.org. level, consider collaborative care involving members of the MHI team. For
patients with a severe risk level, consult with, or consider referral to, a
(f) Comorbid conditions Mental Health Specialist.

Studies show a significant percentage of children with ADHD

have one or more other associated conditions. The most
common comorbid conditions being ADHD with one of the following:AAP1
•• Oppositional defiant disorder (35%)
•• Conduct disorder (26%)
•• Anxiety disorder (26%)
•• Depressive disorder (18%)
Also, a significant percentage of patients with autism spectrum
disorder meet ADHD DSM-5 criteria. GOL While bipolar disorder is often
estimated to occur in fewer than 1% of children and adolescents, these
prevalence rates — and the criteria used to establish bipolar disorder
in children — are controversial. The research generally agrees that
children who do have bipolar disorder also have high rates of ADHD. MCL

©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 5

M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D) DECEMBER 2016
THE KEY TO TREATMENT
The key to treatment is communication
between primary care providers, parents,
and schools — including ongoing follow-
up assessment and treatment adjustment.
Treatment targets should not be based on
symptoms, but rather on identified areas
of impairment in home, school, or social
functioning.
RESOURCES TO HELP
The following resources — available
at intermountainphysician.org/
clinicalprograms under the “Mental Health
Integration (MHI)” topic — can be helpful
for planning, goal setting, following-up,
and communicating.
• ADHD Management: Team Plan can be
used to communicate the treatment plan
with parents and school
staff, set goals for home
and school, and track
progress. See note (b)
on the following page
for more information on
this tool.
• MHI Child &
Adolescent Follow-up
Evaluation Packet and School Follow‑up
Evaluation Packet include the same
validated and impairment scales as the
baseline packets (see sidebar on page 4).
Indicates an Intermountain measure
6 ©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
ALGORITHM 2: TREATMENT PLAN OVERVIEW
Patient Diagnosed with ADHD
INITIAL TREATMENT PLAN
1. Begin medication and consider other treatments as indicated (a).
2. Work with patient/parents to develop a management plan, including medical plan,
follow-up plan, and suggestions for home and school plans (b).
3. Educate parents/patient about ADHD; encourage parents to contact CHADD of Utah and
enroll in ADHD parent education classes (see page 15).
4. Give Child & Adolescent Follow-up Evaluation Packet to complete before next visit and School
Follow-up Evaluation Packet to take to school psychologist/guidance counselor (see left sidebar).
5. Instruct parent to make follow-up visit within 3 to 4 weeks, and to bring
follow‑up packets.
Patient / Parent School
1. Review the ADHD Management:
1. Contact CHADD of Utah and enroll in ADHD
parent education classes. Team Plan with the parent and
2. Initiate home interventions and target behaviors child, and help determine school
based on the patient’s management plan (b). goals and interventions for
behavior management.
3. Take School Follow-up Evaluation Packet and
a copy of the ADHD Management: Team Plan 2. Make special arrangements
as appropriate (Section 504
to the school psychologist/guidance counselor,
establish school goals and interventions, and accommodations, IDEA, etc) (c).
3. As requested by parent and within
request completion of follow-up forms within
3 to 4 weeks. 3 to 4 weeks of initial diagnosis,
4. Complete all forms in the Child & Adolescent complete School Follow-up
Follow-up Evaluation Packet. Evaluation Packet and give a copy
to the parent(s) to take to primary
5. Make a follow-up appointment within 3 to 4
care provider.
weeks and bring completed follow-up forms.
FOLLOW-UP EVERY 3–4 WEEKS
until symptoms controlled and progress toward goals
•• Review follow-up MHI packets from home and school (if available).
•• Monitor height, weight, blood pressure, heart rate, side effects, comorbidities, and
progress toward goals.
•• Activate Mental Health Integration team as appropriate.
•• Reassess diagnosis.
•• Assess adherence to treatment plan or need
Symptoms controlled?
no to modify treatment.
Progress toward goals?
•• Reconsider comorbidities (a).
•• Consider referral to mental health specialist.
yes
ONGOING FOLLOW-UP (every 3 – 6 months)
•• Continue treatment plan.
•• Follow up every 3 to 6 months; have PATIENT/PARENT and SCHOOL complete follow-up packets
before next appointment.
DECEMBER 2016 M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D)

TREATMENT PLAN ALGORITHM NOTES

(a) Treatment options (c) Education accommodations

Ongoing research continues to show that medication and behavioral Educational accommodations for ADHD are shaped by two laws:
coaching by the primary care provider are effective in treating •• Section 504 (Rehabilitation Act of 1973). This law covers
uncomplicated ADHD. Adding behavioral therapy is most appropriate for “disability that substantially limits one or more life activities”
patients with ADHD and comorbid mental health conditions. (and includes learning disabilities). If eligible, the student receives
an Accommodation Plan. For students who can benefit from
simple accommodations, qualifying under Section 504 can be easier
(b) A helpful shared decision-making tool than IDEA. For example, simple accommodations provided under
to plan treatment Section 504 for a child with ADHD might include reducing the number
of homework problems (without reducing the level or content of what
The ADHD Management: Team Plan is helpful in planning treatment, is taught), providing the student with a quiet place to work without
communicating with parents and teachers, setting goals, and distractions, providing extra time for tests, creating a notebook so
tracking progress. teachers and parents can keep each other informed about the child’s
progress, or having a school nurse oversee a student’s medication.
•• IDEA (Individuals with Disabilities Education Act). This act
covers “disability that adversely affects educational performance.”
The act lists 14 disability categories for eligibility; ADHD is included
under “Other Health Impairment.” If eligible, a student receives
an Individual Education Plan (IEP) that may include specially
designed instruction and related services. Students who have an IEP
are also entitled to alternate procedures that must be followed if
they are suspended or expelled. Qualifying under the IDEA may be
a better choice for students who need more extensive services or
accommodations.
See page 16 for more information as well as tips for working with
schools and teachers.
A Medical Plan section A Home Plan section
includes medication includes a to-do list for
instructions, follow‑up parents/families, information
specialist and care on resources, and an area
management appointments, to record at-home goals
and a checklist for monitoring for behavior, relationships,
medication side effects. emotions, and responsibilities.

A School Plan section Ideas for setting and

includes a to-do list for the monitoring goals in
school psychologist/guidance both domains (home and
counselor, information on school) are provided.
resources, and an area to
record school goals for
behavior, relationships,
emotions, and responsibilities.

©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 7

M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D) DECEMBER 2016

ALGORITHM 3: MEDICATION MANAGEMENT

KEYS TO EFFECTIVE
MEDICATION MANAGEMENT
The key to medication management is
frequent, effective communication Decision to Treat with Medications
between primary care providers and
parents during medication trials. To
determine the best medication and dosage yes, or
Cardiac CONSULT
for the patient, carefully monitor side in family
disease? (a) with pediatric
effects and progress based on goals. history
cardiologist
Parents may not always take the initiative
to contact the primary care provider during no
a medication trial, so consider contacting
the parent regularly. USE trial of long-acting STIMULANT (b)

Side Serious side

effects? (c) effects

Manageable or no side effects

CONTINUE,
and FOLLOW Yes Effective?
UP in 3 to 6
months
No

USE trial of 2nd long-acting STIMULANT (b)

Side Serious side

effects? (c) effects

Manageable or no side effects

CONTINUE,
and FOLLOW
Yes Effective?
UP in 3 to 6
months
No

CONSIDER child psychiatric referral OR

a 4- to 6-week trial of NON-STIMULANT (d)

CONTINUE,
and FOLLOW Yes No MAKE child
Effective?
UP in 3 to 6 psychiatric
months referral

8 ©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .

DECEMBER 2016 M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D)

MEDICATION MANAGEMENT ALGORITHM NOTES

(a) Screening for cardiac disease (c) STIMULANT side effects

Stimulant medication is the first-line treatment for ADHD, and there is no •• Possible side effects of stimulants are listed in table 3 on
evidence of increased sudden cardiac death (SCD) in otherwise healthy page 13. Many side effects of stimulants are mild, of short duration,
pediatric patients taking stimulants. However, before prescribing a and reversible with adjustments to dose or dosing interval.
stimulant, patients should be screened for pre-existing heart disease. MCL
•• For mild side effects, use your judgment about continuing with
Cardiac screening should include: dosage adjustments to the current stimulant, switching to another
•• Patient history of previously detected cardiac disease, severe stimulant, or switching to a non-stimulant.
palpitations, arrhythmias, syncope, chest pain, hypertension, or •• If any of the following serious side effects occur, switch
exercise intolerance not accounted for by obesity (specific signs of to a trial of a NON-STIMULANT, AND/OR consider a psychiatric
hypertrophic cardiomyopathy, associated with sudden unexpected consult/referral.
deaths in children and adolescents, include chest pain, arrhythmias,
–– Hallucinations or other –– Obsessive-compulsive
hypertension, and syncope)
psychotic symptoms symptoms
•• Family history focused on sudden death in children or young adults,
–– Depression or extreme –– Increase in ADHD symptoms in
hypertrophic cardiomyopathy, or long QT syndrome
mood swings at least two medication trials
If screening reveals pre-existing heart disease or symptoms –– Significant anxiety –– Continuous tics
that suggest significant cardiovascular disease: Refer the
patient for consultation with a cardiologist before a stimulant trial.

(d) NON-STIMULANT trial

(b) STIMULANT trial (s) •• After two or more failed stimulant trials or based on unpleasant
or serious side effects from stimulants, consider switching to a
•• Stimulant medication is the first-line treatment for ADHD. non‑stimulant medication or, if appropriate, adding a non‑stimulant
Long-acting stimulants are preferred. medication. (Consider a psychiatric consult before initiating
•• A legitimate trial of a stimulant is 3 to 4 weeks, titrating the combination therapy.)
dose if needed over that period. (See table 1 on pages 10-11 for more •• Three of the non-stimulant drugs listed in table 2 on page 12 are
information on the starting dose and maximum level of recommended approved by the FDA for treatment of ADHD: atomoxetine/Strattera,
medications.) During the medication trial, increase the dose to optimal guanfacine ER/Intuniv, and clonidine ER/Kapvay. The other
level without side effects — see note (c) below. Also, use each trial non‑stimulant medications are off-label; consider the off-label
to assess the accuracy of ADHD and/or comorbidity diagnosis. medications with caution.
•• Careful, frequent monitoring of the patient during each
•• Within the non-FDA approved options in table 2, consider an
medication trial is important. Encourage patients/parents to
antidepressant if mood lability or depression is prominent or an
inform you about medication side effects, and see table 3 on
alpha‑adrenergic agonist if hyperactive/impulsive symptoms or
page 12 for a summary of suggested monitoring steps for each
aggression are most prominent. THO
medication. The ADHD Management: Team Plan contains a checklist
to help patients monitor side effects; if the Team Plan is not used,
consider giving parents a copy of the medication follow-up page from
the MHI Child & Adolescent Follow-up Evaluation Packet. Parents
may not always take the initiative to contact the primary care provider,
so consider contacting the parent regularly.
•• Use stimulants with caution in patients with a history of
drug or alcohol dependence or with possibilities of misuse,
including distribution to others.
•• For patients with comorbidities, consider consulting a
mental health specialist before choosing medication. Specific
medication choices can be more effective for specific comorbidities.
See note (d).

©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 9

M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D) DECEMBER 2016

TABLE 1. STIMULANTS used in ADHD treatment LEX,DRUG (See page 13 for side effect profiles and monitoring recommendations.)

Pediatric dose Adult dose1

Drug Forms and Tier, cost 2
Duration Daily Daily
(Brand Name) administration Initial Initial Brand (generic)
Max Max
amphetamine 13 hours •• 2.5 mg / mL extended-release oral Age ≥ 6: 20 mg 2.5 – 5 mg / day 20 mg Not covered, $$$$
suspension 2.5 – 5 mg / day (No generic)
(Dyanavel XR)
amphetamine 10 to 12 •• 5, 10, 15, 20, 25, 30 mg Age ≥ 6: 30 mg 20 mg / day 60 mg Tier 3, $$$$
mixed salts hours extended-release capsules 5 – 10 mg / day (Generic: Tier 1, $$$)
(Adderall XR) •• Swallow whole, sprinkle on
applesauce Ages 13 – 17:
10 mg / day
lisdexamfetamine 10 to 12 •• 10, 20, 30, 40, 50, 60, 70 mg Age ≥ 6: 70 mg 30 mg / day 70 mg Tier 2, $$$$;
hours extended-release capsules (No generic)
LONG ACTING (PREFERRED)

(Vyvanse) 30 mg / day
•• Swallow whole, or mix in water,
yogurt, or orange juice
dexmethylphenidate 10 to 12 •• 5, 10, 15, 20, 25, 30, 35, 40 mg Age ≥ 6: 30 mg 10 mg / day 40 mg Tier 2, $$$$,
hours extended‑release capsules 5 mg / day (Generic: Tier 1,
(Focalin XR)
•• Swallow whole, sprinkle on $$$-$$$$; available in 5, 10,
applesauce 15, 20, 30, and 40 mg)

methylphenidate HCl 54 mg

(Concerta) 10 to 12 •• 18, 27, 36, 54 mg Age ≥ 6: (Ages Tier 33, $$$$
18 – 36 mg / day 72 mg
hours extended-release tablets 18 mg / day 6 – 12 (Generic: Tier 1, $$$$)
•• Swallow whole ONLY)

(Quillivant XR) 12 hours •• 5 mg / mL extended-release oral Age ≥ 6: 60 mg 20 mg / day 30 mg Tier 3, $$$$
suspension 20 mg / day (No generic)
(Quillichew ER) 8 hours •• 20, 30, 40 mg extended-release, Age ≥ 6: 60 mg 20 mg / day 60 mg Tier 3, $$$$
chewable tablets 20 mg / dayy (No generic)

methylphenidate 10 to 12 •• 10, 15, 20, 30 mg transdermal patch Age ≥ 6: 30 mgDRU 10 mg / day 60 mg Tier 3, $$$$
hours •• Apply 2 hours before desired effect 10 mg / day (No generic)
(Daytrana)
Not FDA approved

dextroamphetamine 6 to 8 hours •• 5, 10, 15 mg timed-release capsules Age ≥ 6: 40 mg 10 mg / day 60 mg Tier 3, $$$$,
sulfateDEXE •• Swallow whole, sprinkle on 5 mg, once (Generic: Tier 1, $$$)
applesauce or twice daily
(Dexedrine, Spansule) Not FDA approved
INTERMEDIATE ACTING (PREFERRED)

methylphenidate ER 20 mg / day 60 mg

Age ≥ 6: Tier 1, $$
(Metadate ER) 6 to 8 hours •• 20 mg extended-release tablets 20 mg / day Not FDA approved (Generic: Tier 1, $$)
•• Swallow whole
60 mg
(Aptensio XR) 5 to 6 hours •• 10, 20, 30, 40, 60 mg extended- Age ≥ 6: 10 mg / day 60 mg Tier 3, $$$$
release tablets 10 mg / day (No generic)
•• Swallow whole or sprinkle on
applesauce
methylphenidate SR 6 to 8 hours •• 20 mg extended‑release tablets Age ≥ 6: 60 mg 20 mg / day 60 mg (Generic ONLY:
(Ritalin SR) •• Swallow whole 5 mg twice Tier 1, $$)
daily
methylphenidate 8 hours •• 10, 20, 30, 40, 50, 60 mg Age ≥ 6: 60 mg 20 mg / day 60 mg
ER, CD extended-release capsules 20 mg / day Tier 3, $$$$
(Metadate CD) •• Swallow whole or sprinkle on (Generic: Tier 1, $$$-$$$$)
applesauce Not FDA approved

methylphenidate 6 to 8 hours •• 10, 20, 30, 40, 60 mg extended- Age ≥ 6: 60 mg 20 mg / day 60 mg Tier 3, $$$$
ER, LA release capsules 20 mg/day (Generic: Tier 1, $$$$, 10 mg not
(Ritalin LA) •• Swallow whole or sprinkle on available)
applesauce

NOTE: Table continues on page 11 with footnotes from above at end of table.

10 ©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .

DECEMBER 2016 M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D)

TABLE 1. STIMULANTS , CONTINUED LEX,DRUG — See page 13 for side effect profiles and monitoring recommendations.

Pediatric dose Adult dose*

Drug Forms and Tier, cost 2
Duration Daily Daily
(Brand Name) administration Initial Initial Brand (generic)
Max Max
amphetamine 4 to 6 hours •• 5, 7.5, 10, 12.5, 15, 20, 30 mg Age ≥ 6: 40 mg 10 mg / day 60 mg Tier 3, $$$$
mixed salts tablets 5 mg, once or (Generic: Tier 1, $$)
twice daily
(Adderal) •• Swallow whole
Age 3 – 5:
2.5 mg/day
amphetamine 4 hours •• 5, 10 mg tablets Age ≥ 6: 40 mg 5 – 10 mg / day 40 mg Not covered, $$$$
sulfate •• Swallow whole 5 mg, once or (No generic)
(Evekeo) twice daily
Age 3 – 5: Not FDA approved
2.5 mg/day

dexmethylphenidate 3 to 5 hours •• 2.5, 5, 10 mg tablets Age ≥ 6: 20 mg 2.5 mg twice 20 mg Tier 3, $$$
•• Swallow whole 2.5 mg twice daily (Generic: Tier 1, $-$$)
(Focalin)
daily
SHORT ACTING (SECONDARY)

dextroamphetamine Tier 3, $$$$

sulfate IR Age ≥ 6: (Generic: Tier 1, $$-$$$$ (2.5,
•• 2.5, 5, 7.5, 10, 15, 20 mg tablets 5 mg, once or 7.5, 15, 20, 30 mg not avail-
5 mg once or
(Zenzedi) 4 to 6 hours •• Swallow whole twice daily twice daily 40 mg able)
(Dexedrine) 4 to 6 hours •• 5, 10 mg tablets Age 3 – 5:
2.5 mg / day 40 mg
•• Swallow whole
Tier 3, $$$$
(Procentra) 3 hours •• 5mg / 5mL oral solution Age 3 – 5: (Generic: Tier 1, $$-$$$$)
2.5 mg / day Not FDA approved
Age 6 – 16:
5 mg, once or
twice daily
methylphenidate
(Methylin) 3 to 5 hours •• 5 mg / 5 mL, 10 mg / 5 mL suspension; Age ≥ 6: 60 mg 5 mg / day 60 mg Tier 3, $$$$
5 mg, twice twice daily (Generic: Tier 1, $$)
•• 2.5, 5, 10 mg chewable tablets
•• Swallow / chew and swallow daily

(Ritalin) 3 to 5 hours •• 5, 10, 20 mg tablets Age ≥ 6: 60 mg Initial: 5 mg 60 mg Tier 3, $$$$
•• Swallow whole 5 mg, twice daily (Generic: Tier 1, $-$$)
twice daily
methamphetamine 3 to 5 hours •• 5 mg tablets Age ≥ 6: 25 mg 5 mg once or 25 mg Tier 3, $$$$,
•• Swallow whole 5 mg, once or twice daily (Generic Tier 1, $$$)
(Desoxyn)
twice daily
Not FDA approved

1
Some doses shown are not FDA approved for treatment of adults with ADHD (as indicated in the note within each medication’s dosage column).
2
Tier and cost: Tier 1 = $10 copay; Tier 2 = $30 copay; Tier 3 = $70 copay for 30-day prescription (based on RxSelect 2015 benefit design; benefit designs may differ). Cost
is based on 30-day actual cost (not copay) and generic unless otherwise noted: $ = $1 to $25; $$ = $26 to $75; $$$ = $76 to $150; $$$$ = over $150. For the most
recent SelectHealth formulary information, visit http://www.selecthealth.org or call 801-442-4912 (option 1) or 800-442-3129 (option 1).
Actavis is currently the only methylphenidate ER generic that carries an A-B equivalence rating to brand Concerta from the FDA. All other manufacturers’ methylphenidate ER
3

generics are not considered bioequivalent but are still FDA approved to be manufactured and dispensed; however, these other generics cannot be interchanged for Concerta
brand at point of sale.

©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 11

M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D) DECEMBER 2016

TABLE 2. NON-STIMULANTS USED IN ADHD TREATMENTLEX,DRUG (See page 13 for side effect profiles and monitoring recommendations.)

Pediatric dose Adult dose1

Drug (Brand) Duration Forms and administration Initial Daily Max Initial Daily Max Tier, cost 2

atomoxetine 10 to 12 •• 10, 18, 25, 40, 60, 80, Ages ≥ 6, 1.4 mg / kg or 100 mg, 40 mg / day; 100 mg / day2 Tier 3, $$$$
(Strattera) hours 100 mg capsules < 70 kg: whichever is less2 once daily (No generic)
0.5 mg / kg / day or 2, evenly
•• Swallow whole
divided
≥ 70 kg:
doses)
40 mg / day2
FDA-APPROVED

guanfacine ER 12 hours •• 1, 2, 3, 4 mg extended-release Ages 6 – 17: Ages 6 – 12: 4 mg 1 mg / day 7 mg / day Tier 3, $$$$,
(Intuniv) tablets 1 mg once once daily once daily (Generic: Tier 1,
daily $$$$)
•• Swallow whole Ages 13 – 17: 7 mg Not FDA approved
once daily

clonidine ER 12 hours •• 0.1 mg extended-release Age ≥ 6: 0.2 mg twice daily 0.1 mg / day 0.2 mg twice Tier 3, $$$$,
(Kapvay) tablets 0.1 mg / day (0.4 mg / day) daily (0.4 (Generic: Tier 1,
mg/day) $$$)
•• Swallow whole
Not FDA approved

clonidine 6 to 10 •• 0.1, 0.2, 0.3 mg tablets or ≤ 45 kg: ≤ 45 kg: 0.1 mg / day 0.4 mg / day, Tier 3, $$,
(Catapres) hours transdermal system 0.05 mg / day 0.2 mg / day, in in divided (Generic: Tier 1, $)
(tablets) at bedtime divided doses doses
Not FDA approved for treatment of ADHD (off label)

•• Swallow tablets whole; when

titrated to optimal, stable oral > 45 kg: > 45 kg:
dose, may switch to equivalent 0.1 mg / day at 0.4 mg / day, in
transdermal dose bedtime divided doses
3
guanfacine 17 hours •• 1, 2 mg tablets ≤ 45 kg: 27 – 40.4 kg: 1 mg / day 4 mg / day Tier 3, $$$$,
(Tenex) 0.5 mg / day at 2 mg / day in divided (Generic: Tier 1, $)
•• Swallow whole; if switching
bedtime doses
from immediate release (IR),
discontinue IR and titrate > 45 kg: > 45 keg:
dose of extended release (ER) 1 mg / day at 4 mg / day in divided
starting with 1 mg daily bedtime doses

bupropion 450 mg / day
(Wellbutrin) •• 75, 100 mg film-coated tablets 100 mg (in 3 to
twice daily 4 divided
•• Swallow whole
3 mg / kg / day doses)
or
(Wellbutrin SR) •• 100, 150, 200 mg 300 mg / day 150 mg 400 mg / day
14 to 30 150 mg / day, Tier 3, $$$
3
extended-release tablets (in 2 or 3 divided once daily (in 2 divided
hours whichever is (Generic: Tier 1, $)
doses) doses)
•• Swallow whole least

(Wellbutrin XL) •• 150, 300 mg 150 mg 450 mg once

extended-release tablets once daily daily
•• Swallow whole

1
Some doses shown are not FDA approved for treatment of adults with ADHD (as indicated in the note within each medication’s dosage column).
2
Tier and cost: Tier 1 = $10 copay; Tier 2 = $30 copay; Tier 3 = $70 copay for 30-day prescription (based on RxSelect 2015 benefit design; benefit designs may differ).
Cost is based on 30-day actual cost (not copay) and generic unless otherwise noted: $ = $1 to $25; $$ = $26 to $75; $$$ = $76 to $150; $$$$ = over $150. For the
most recent SelectHealth formulary information, visit http://www.selecthealth.org or call 801-442-4912 (option 1) or 800-442-3129 (option 1).
3
Half life of medication; duration has not been established.

12 ©2002–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .

DECEMBER 2016 M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D)
TABLE 3. SIDE EFFECT PROFILES AND MONITORING RECOMMENDATIONS MCL,WIL
Medication Side effects
stimulants •• Appetite disturbance or anorexia,
sleep disturbance, weight loss,
transient headache, stomachache
•• Less commonly include increased
heart rate and blood pressure,
social withdrawal, headache,
irritability, nervousness, abdominal
pain, motor tics (usually transient)
atomoxetine Weight loss, abdominal pain,
(Strattera) appetite disturbance, vomiting,
nausea, dyspepsia, sleep disturbance,
motor tics
guanfacine/ Headache, fatigue, abdominal pain, •• If history and physical exam reveals
clonidine sedation, syncope, depression,
bradycardia, hypotension, xerostomia
bupropion Dizziness, nausea, agitation,
xerostomia, constipation, motor
tics, lower seizure threshold, cardiac
dysrhythmia
©2002–2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .
Monitoring
•• If history and physical exam reveals
heart disease (see page 9) consult with
cardiologist for initial evaluation
and monitoring
•• Routinely monitor blood pressure, heart
rate, and growth
•• Monitor for mania, hallucinations,
emergent psychotic or manic symptoms,
obsessive-compulsive symptoms,
significant anxiety (consider non‑stimulant
or a psychiatric consult for these
symptoms)
•• Monitor for liver injury, suicidal thinking
and behavior, unusual behavior, worsening
symptoms, psychotic or manic symptoms,
hallucinations or delusions
•• Routinely monitor BP and heart rate
heart disease (see page 9) consult with
cardiologist for initial evaluation
and monitoring
•• Routinely monitor BP and heart rate
Monitor for suicidal thinking or behavior
(particularly in first few months of therapy or
following changes of dosage)
Other comments
•• Many side effects of stimulants are mild, of short
duration, and reversible with adjustments to dose
or dosing interval
•• Use caution with patients who have a history of
drug or alcohol dependence or with possibilities
of misuse, including distribution to others
•• Consult with cardiology before use in patients
with structural cardiac abnormalities
•• In patients with comorbid tic disorders,
methylphenidate is preferred as it does not
appear to worsen tic symptoms BLO
•• Advise families and caregivers of need for close
monitoring
•• Consult with cardiology before use in patients
with structural cardiac abnormalities
•• May be beneficial for ADHD patients with
comorbid tic disorders BLO
•• Taper to avoid rebound hypertension
•• If switching from immediate release (IR),
discontinue IR and titrate dose of extended
release (ER); start with 1 tablet/day
•• May be beneficial for ADHD patients with
comorbid tic disorders BLO
•• May be used alone or adjuvant to another
medication for ADHD
Contraindicated in patients with a current seizure
disorder, as it lowers seizure threshold
13
M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D) DECEMBER 2016

RESOURCES FOCUSED ON PATIENT AND FAMILY EDUCATION

PATIENTS AND FAMILIES
The keys to effective patient and family education are:
To help you coach parents on these topics,
Intermountain Healthcare offers several • Helping parents understand ADHD and common comorbidities
education handouts for patients and
families. Classes, support groups, and • Connecting patients and parents to resources
websites are also available through CHADD
• Helping parents set goals with their child and understand their child’s ADHD
and other organizations.
management plan
• Education materials. These materials
are available on intermountain.net and can • Helping parents understand medication options, risks, and benefits
be ordered at minimal cost (see page 16).
• Helping parents work with their child’s teachers
–– Attention Deficit
Hyperactivity Disorder:
An 8-page handout Why education is important
that describes ADHD,
diagnosis, treatment Patients and their families need education about ADHD and how to deal with the
options, tips for impairments it may cause. Parents may experience stress, self-blame, social isolation,
management at home and and depression while trying to raise a child with ADHD. They may feel completely
school, and resources. overwhelmed. If left untreated, ADHD can have devastating effects that can escalate
–– ADHD: Talking with Your as a child grows older, as shown below.
Child:
A 4-page fact sheet that
explains a recommended Possible effects of untreated ADHD as a child ages:
approach (with an example
conversation) and covers Age 6 Age 10 Age 14 to 16
how to help a child adjust • Low • Disruptive • Challenging • Criminal behavior • Conduct disorder
to medication, how a child can explain self‑esteem behavior behavior • School exclusion • Lack of motivation
ADHD to friends and classmates, and • Poor social skills • Oppositional • Complex learning
• Substance abuse
how to help the family adjust. defiant disorder difficulties
• Learning delay • Teenage pregnancy
–– ADHD in Adults:
A 4-page fact sheet that
explains the symptoms
of ADHD in adults,
the diagnosis process, What parents need to know
treatments, and effective To care for their child with ADHD, parents need to learn:
ways to manage the
condition. • What ADHD is, other conditions that are likely to exist with it, and what types
• Classes: CHADD of Utah offers of behavior problems they can expect
Parent to Parent: Family Training on ADHD, • What treatment options are available, and when or if behavioral therapy is
a program endorsed by the American
Academy of Pediatrics. Find the
appropriate
schedule and registration information at • The medication options that are available, the risks and benefits of medication,
CHADDofUtah.com. (Classes and printed
and the long-term benefits of staying on medication long-term
materials from CHADD are also available
in Spanish.) • What behavior modification plans are age-appropriate for their child
• Other organizations and websites
• What educational laws are in place to service children with ADHD and which
that provide education about ADHD are
listed on page 16. educational strategies will help their child best
• How to advocate for a child with ADHD in various settings — with extended
family, in the neighborhood, with medical professionals, at school, and in
sports programs

14 ©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED .

DECEMBER 2016 M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D)

SUMMARY OF INTERMOUNTAIN RESOURCES

OTHER WEB RESOURCES
For providers: For providers:
To find all the ADHD tools described • ADHD topic sponsored by the
in this CPM, clinicians can go American Academy of Pediatrics,
to intermountainphysician. National Initiative for Children’s
org/clinicalprograms, choose Healthcare Quality (NICHQ):
“Clinical Topics A–Z,” and then choose nichq.org/areas_of_focus/
“Attention Deficit Hyperactivity Disorder” adhd_topic.html
from the A to Z menu. A Clinical Topic
• American Academy of Pediatrics:
Page (see the example at right) provides
access to CPMs and supporting tools. aap.org (Search for ADHD)
Resources include: • National Institute of Mental Health
ADHD portal: nimh.nih.gov/topics/
topic‑page-adhd.shtml

For patients:
Care Process Flowchart M Ay 2 0 1 4

M E N TA L H E A LT H I N T E G R AT I O N

Addressing Children’s Mental Health:

A Process for Parent-Clinic-School Collaboration
The Mental Health Integration (MHI) program at Intermountain Healthcare strives for collaboration between

• Children and Adults with Attention

parents, schools, and clinicians. Our focus is always on the child, and we want to provide a clear communication path MHI Tools
for educators and clinicians to support parent decisions and achieve the best outcomes for the child. To find education materials, MHI screening packets, and
community resources, visit intermountainhealthcare.org.
The flowchart on the back of this handout presents a model for parent-clinic-school collaboration to access and address
Search for “Mental Health and Behavior,” or click
a child's mental health. Everyone involved with the child should be watchful for mental health issues — and reach out Intermountain Patient Education from the Resources list.
for help when issues arise.

Who participates in the collaboration? For paTIenTs and FACT SHEET FOR PATIENTS AND FAMILIES

Eating Disorders

scHools
Are you struggling with an eating disorder — or
concerned about someone who is? This handout is for you. “For me, treatment

Two teams collaborate to meet the needs of students with mental health issues:
It gives basic information about different eating disorders took a long time.
and lists resources where you can learn more and get help. I knew I had bulimia,

Depression
Treatment by a medical care team vastly improves the
chances of recovery. If you think you or someone you care
but I didn’t want help.
My mom pushed me
to talk to my doctor,
I n f o r m at I oabout
n might
f o rhavepat
an eating
Ien disorder,
ts a reach
nd out for
f ahelp.
mIlIes and I’m now glad she
Eating disorders can be overcome — leading to a happier,
did. I’m not ‘healed,’
more hopeful life.
but I’m trying.”

What are eating disorders?

INsIDe:
Eating disorders are complex problems that affect how
you feel and how you think about yourself. Because they

Education materials are available

What are the symptoms
are often misunderstood and often hidden, it’s unclear
Attention Deficit Hyperactivity
of depression?.......................2
how many people have eating disorders. What we do
What brings on
know is that eating disorders affect a large number of What causes eating disorders?

• The clinic MHI team includes parents (and child), a primary care physician (PCP) or
Disorder (ADHD) depression?..............................2
people — men and women, young and old.
Do other illnesses It’s not This
clearyear,
whynearly
some1 people
in 10 have eating disorders and
There are many types of eating disorders. The two most
co-exist with depression?.........3 others don’t. Anadults
American eatingwill
disorder
have may stem from many
I N F O R M AT I O NHow
FO R PAT I E Ncommon
is depression T S Aare
N anorexia
D FAnervosa
M I L Iand
E Sbulimia nervosa. factors, depression.
including:If you — or
These two disorders, along with other types of eating
diagnosed?............................3 someone you love — is
• A drive for perfection. This drive can be fueled
disorders, are described on the next page.
How is depression treated?....4 suffering from this disease,
by media and cultural images that show unrealistic

on various mental health issues,

Deficit / Hyperactivity Disorder:
read on. This booklet gives
If you’re worried about yourEating disorders have several things in common. They thinness, or by family and friends who value
you the information you need
child or teen..........................6
all tend to occur in people who have one or more of “fitting in” with adepression
certain body size, shape, or weight.
to understand
INSIDE: Family or friend? the following:

pediatrician, nurses, nurse practitioners, mental health care providers, specialists, and others.
• Someand get the support
athletics. you
For example, sports that emphasize
What are the types and What you can do ...................7 need to (like
manage it.
• Obsession with food and weight. They have appearance gymnastics and figure skating) or
symptoms of ADHD?................2Self-management
thoughts about what they eat and what they weigh. where weight gives a competitive advantage (like long
What causes ADHD?................2action plan ..........................8
These thoughts take up much of the day. distance running and wrestling).
How is ADHD diagnosed?.........3 Do you have questions• Emotional and personality disorders. Depression,
• Distorted body image. They may see themselves
How is ADHD treated?.............4 DepressIoN Is a as fat, even when underweight. about attention deficit anxiety, traumatic life events, and a desire for control

including ADHD, depression, autism,

How to help your child FamIly aFFaIr… What is depression?
hyperactivity disorder may lead to eating disorders.
• Frequent and excessive exercise. They often exercise
with ADHD.............................6 When you have depression, your (ADHD)? This booklet
obsessively to staydepression is anoff
thin or to burn illness
whatcaused by problems
they eat. with
Thisthe
listchemicals
in no wayincovers
your every
brain.factor that can cause
will help you understand
Where to learn more................7loved ones are also affected. this chemical imbalance affects how you feel,eating think,disorders.
and act. so
Theit’s wrong
cause of an eating disorder is unique
this disorder and learn
They might worry that they’reWho gets eating to seedisorders?
depression as a weakness or character flaw. research
to each hasexperiences,
person’s shown thatgenetics,
it’s environment, and

The family is the

Myths and truths......................8 to manage it.
somehow causing your moods. Anyone can develop aanmedical illness just
eating disorder. likeare
They diabetes
most or high blood pressure.
other personal factors.
They may be angry with youcommon in young women (teenagers and young adults),
there’s a lot of variety in how people experience depression. It can be mild

• The school team includes parents (and child), teacher, school counselor, school psychologist,
for being down, or afraid of but
the they can happen to people of any gender, race, age,
changes they see in you. or weight.
or severe. You might have it only once in your lifetime, have several episodes
1

anxiety disorders, eating disorders,

over time, or have ongoing depression. Your symptoms may differ from those

“
Help your loved ones by sharing
What a difference a year the information in this booklet.
of other people with depression.
What is ADHD?
has made! Danny earns

center of both
The more they understand the despite its various patterns, you should always take depression seriously.
much better grades now disease of depression, ADHD is a biological disorder that affects how the brain functions and
the Untreated, depression can make it hard to be a good spouse, friend, or parent.
and has a good attitude. more they’ll be abledevelops.
to support
People with ADHD have trouble paying attention, sitting still,
It can hurt you at work and prevent you from taking care of yourself. It can
He’s making friends and or controlling
your recovery and ease their their behavior.
prompt you to pull back from the world — and may even lead to suicide.
getting along with all of us own minds.
Many people have behaviorsthe thatgood
are like ADHD symptoms, especially

administrator, and other school personnel as needed (e.g., special ed teacher, reading specialist).
at home, too. Our whole news? depression can be treated. most people Can recover and
family just works better. children. The difference withleadADHD is that these
full, productive symptoms are chronic
lives.

suicide ideation, and more.

(long lasting) and they interfere with daily life. For example, people with

teams.
You know, I wasn’t happy
ADHD often have trouble at school or work. They may also struggle to
about Danny’s ADHD
diagnosis. But I’m grateful learn from past mistakes or predict how their choices will affect the future.
now. He needed Their personal relationships can suffer. And as a result, they may feel
treatment — and he’s anxious, unsure of themselves, and depressed.

”
getting it.
ADHD is a serious condition that affects up to 1 in 10 schoolchildren in
— Miriam , Utah, and it often persists into adulthood. Right now, there’s no cure for
mother of a child ADHD. But with early and proper treatment, most people with ADHD can
with ADHD enjoy better relationships and self-esteem — and have a much better chance
of reaching their full potential.

These teams work together to share information and give parents access to the most effective treatments and For scHools
interventions for the child. The schools provides the MHI team with feedback using evaluation packets (see sidebar);
You’ll complete these packets to Mental Health

the MHI team communicates care plans and any other pertinent information with the school team and the parents.
Integration

communicate your assessment of the

School Follow-up Evaluation Packet

Today’s Date:

Mental Health

physician/office staff
Student’s Name: Student’s Phone:

To be filled out by
Clinic Name:
Integration
Physician Name: Clinic FAX:
Clinic Phone:

student to the MHI team:

School Baseline Evaluation Packet
Clinic Address:

Zip:
Today’s Date:

Which children may benefit?

physician/office staff
Student’s Name: Student’s Phone:
Dear School Psychologist, Guidance Counselor, or Teacher;

To be filled out by
Physician Name: Clinic FAX:
The student listed above has been diagnosed with ADHD or another mental health condition. The parent may
Clinic Name: Clinic Phone:Plan, which lists medications and follow-up instructions —
have been given an ADHD Patient Management
Clinic Address: as well as treatment goals for home and school. We are asking for your cooperation in the following:

1] Meet with the student and parent(s). Zip:

Arrange a meeting with the student and parent(s) to discuss the needs of the student and prepare a

MHI School Baseline Packet

Dear School Psychologist, Guidance Counselor, or Teacher,
course of action (intervention plan). If the student has been diagnosed with ADHD, the ADHD Patient

•
The student listed above is being evaluated by our clinic for symptoms possibly associated with Attention Deficit
Management Plan can be used to guide this process.
Hyperactivity Disorder (ADHD) or another mental health condition. Your input is important in this process — it
is necessary to make an accurate diagnosis and form a treatment plan. This packet contains the following forms:
2] Complete the attached Vanderbilt ADHD TEACHER Rating Scale and the School Impairment Scale.
ˆ Vanderbilt ADHD TEACHER RatingAfter
Scaleinitial
(This diagnosis,
scale helps we aimsymptoms
assess to re-evaluate the student
of attention — andproblems
or hyperactivity assess progress
and toward goals and
resulting degree of impairment. It also screens for anxiety,side
any medication depression, oppositional
effects — within 3–4defiant disorder,
weeks and conduct
of diagnosis. disorder.)
Along with symptoms of ADHD, the
Vanderbilt
ˆ School Impairment Scale (This scale scaledomains
helps identify assesses of
symptoms of anxiety, which
greatest impairment, depression, oppositional
can help guide furtherdefiant disorder, and

Children with diagnoses (or behaviors consistent with) attention deficit hyperactivity disorder (ADHD), depression,
conduct
evaluation, goal setting, and monitoring disorder.
of treatment effects.)

MHI School Follow-up Packet

ˆ OTHER: Once the patient’s symptoms are stable, we will follow up approximately every 3 to 6 months and may

•
request additional feedback at those time intervals.
We would like you to complete these forms as soon as possible. Generally, the student’s teacher (or whoever

chadd.org
spends the most time with the child) is the communication
Ongoing best person to complete forms. Ifisthe
these progress
about student child has
essential for more
makingthan one decisions about the
accurate
primary teacher, or has a special education
maintenance teacher, it would be
or adjustment of useful for usintervention
the current to obtain a separate
plan andset of ratingregimen. We truly appreciate your
treatment
scales from each teacher. Please make copies of the attached forms as needed for this purpose.
cooperation and insight in providing the best possible care for this child.
There are two options for returning the completed forms:
1. Return them to the student’s parent. The parent can then make a follow-up appointment with our office.
2. With the parent’s permission (see below), you can return the forms to our clinic at the address listed above.

autism, anxiety disorders, bipolar disorder, eating disorders, suicide ideation, and other mental health issues are most
The school has my permission to return forms directly to the clinic.
Parent Signature
Signature of Primary Care Provider
You may decide to do a more thorough evaluation at your discretion. If additional testing is done, please also send
a copy of the psych report to our office.
©2004–2013 Intermountain Healthcare. All rights reserved.

If our evaluation shows thatAD008

this (Full
child does
School
Patient and Provider Publications 801-442-2963
haveEvaluation
Follow-up ADHD, we -will
Packet) 11/13communicate an ADHD Patient Management
*50402*
MHI Pack 50402
Plan through the parent. Management of ADHD requires ongoing communication between the primary care
provider, the parent, and the school. Therefore, this child’s parent may request ongoing feedback from you
regarding the child’s progress, including medication monitoring.
We appreciate your collaboration in providing the best care for this student. Thank you.

appropriate for care in this model. The model can be used for children and teens in elementary and high school.
Signature of Primary Care Provider
©2004–2013 Intermountain Healthcare. All rights reserved.
Patient and Provider Publications 801-442-2963
ADD007 (Full School Baseline Packet) - 11/13
*50402*
MHI Pack 50402

The goals of our collaboration

• Focus our attention on the most important members of the team — the child and the parents — to help parents make
educated decisions about their child’s care.
• Tap into the child's support system to increase consistency, efficiency, and effectiveness of the care intervention.
• Improve communication and accelerate understanding about how to address concerns for the individual child.

If you have comments or questions about this process, please email the director of MHI, Brenda Reiss-Brennan, with your feedback: brenda.reiss-brennan@imail.org.

Addressing • Utah Children and Adults with

Children’s Mental Attention Deficit / Hyperactivity
ADHD Care ADHD Patient Scoring instructions and tools Health: A Process for
Process Model
Disorder: chaddofutah.com
Management Plan Parent-Clinic-School
Collaboration • National Resource Center on ADHD
(for adults and children):
Care Process Model References help4adhd.org, which includes
For a full list of references used in this CPM, see: Attention Deficit Hyperactivity Disorder helpful “What We Know”
sheets on over 20 topics,
CPM Reference List.
available in English and Spanish:
help4adhd.org/en/about/wwk
For patients and • ADHD Medication Guide produced
teachers: ADHD:Tips for Teachers
by the American Academy of Child
If you’re a teacher, you probably have several students with ADHD — and you may have more questions
than answers. This handout explains what ADHD is and provides helpful guidelines and tips.

What is ADHD (Attention Deficit Hyperactivity Disorder)?

and Adolescent Psychiatry and the
• Clinicians can access
“

American Psychiatric Association:

ADHD is a biological disorder caused by underactivity in certain portions of the brain. This
underactivity causes the three main behaviors of ADHD: hyperactivity, inattention, and impulsivity.
At school, a child with ADHD may have trouble paying attention, sitting still, or regulating
behavior. His or her desk will often be messy, papers will be lost, and assignments will
sometimes be finished but not turned in. These problems will come and go, depending on
how stimulating the activity is to the child on that particular day. All children can have
behaviors in common with ADHD at times. However, ADHD is a chronic condition that I like my teacher!
interferes with daily life, causing trouble at school and at home. If left untreated, it can inhibit But I can’t listen

Intermountain ADHD patient

or slow the normal social, emotional, and academic progress of the child. sometimes.

parentsmedguide.org
There are so many other
Types and symptoms of ADHD things to watch and do.
ADHD symptoms are often identified at school. ADHD is classified into 3 types, based on She said she told me
three times to sit
patterns of behavior:
down, but I only heard
• Hyperactive-impulsive type her once.
– Fidgets or squirms, seems or feels restless
– Has trouble being quiet —Elliot,
– Has trouble taking turns or waiting in line Second grade student

”
– Interrupts or blurts out answers before hearing the whole question

education materials using

– Runs about or climbs too much, seems “driven by a motor”
• Inattentive type
– Is often distracted and makes careless mistakes
– Has trouble focusing and organizing
– Can seem apathetic or “lazy”
– Doesn’t follow through
“
– Often forgets and loses things
• Combined type: People with this type of ADHD show symptoms from both categories above.
This type is the most common: 50% to 75% of people with ADHD have the combined type.

the clinical topic pages

I have a student
What if I notice a student has ADHD-like behaviors? with ADHD-like
The classroom requires self-control and attention, so symptoms that might indicate ADHD behaviors.
often emerge at school. It’s important to take appropriate action when they do: I’d like to know what I
1 If you notice ADHD-like behaviors before a parent expresses concern, begin by can do for him within my
using teaching techniques to help manage behavior (page 2). role. Elliot’s a great kid —
he’s capable of a lot more.
2 If the behavior continues, follow your school’s protocol and Utah state guidelines
for identifying, evaluating, and discussing ADHD (page 3). This includes cooperating with
school-based evaluation.
—Ruth,
Second grade teacher

described above, and order

3 If a student is diagnosed with ADHD, work with parents to on a behavior
modification plan, accommodations (if appropriate), and ongoing communication (page 4).
”

copies via iprintstore.org. Attention Deficit ADHD: Tips for Teachers Fact sheets:
Hyperactivity (4-page handout) • ADHD: Talking with Your
Call 801-442-3186 for more Disorder (8-page Child or Teen
information. color handout) • ADHD: Talking to Your
Child or Teen’s Teachers
• Appropriate materials will also • ADHD in Adults
appear in iCentra based on
diagnosis code, or they can be
found through the Education Module.

• Patients and teachers can be referred

to Intermountain’s public website at
intermountainhealthcare.org for
information, tools, and links to other
web resources.

©2002–2016 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED . 15

M A N AG E M E N T O F AT T E N T I O N D E F I C I T H Y P E R AC T I V I T Y D I S O R D E R ( A D H D) DECEMBER 2016
RESOURCES FOCUSED ON
SCHOOLS
The following resources are available
for parents and teachers to access
and print from the public website at
intermountainhealthcare.org/adhd.
• ADHD: Tips for Teachers:
A 4-page handout available for teachers that
covers talking with parents about symptoms
while remaining in compliance with Utah
legislation; it also includes suggestions for
ADHD management.
• ADHD: Talking to Your Child’s or
Teen’s Teachers:
A 4-page fact sheet for parents that
includes suggestions for working with a
child’s teachers on ADHD interventions.
• Addressing
Children’s
Mental Health: A Process for
Parent-Clinic-School Collaboration:
This flow chart provides further detail on
how the schools implement their part of
this CPM, along with three tiers of school
interventions/support.
For more information on laws governing
teacher involvement and/or
education accommodations, see:
• Utah Medical Recommendations for
Children Act (H.B. 202, 2007):
le.utah.gov/~2007/bills/hbillenr/hb0202.htm
• Explanation of the differences between
Section 504 and IDEA, focused on
accommodations for students with
ADHD: chadd.org/Understanding-ADHD/
For-Parents-Caregivers/Education/
Section-504.aspx
Other Internet resources include:
• The Utah Quest for What’s Best website
provides information for schools, clinicians,
and parents, including communication
tools, Utah resources, and a care process
flow chart: questforwhatsbest.info
• Teaching Children with Attention Deficit
Hyperactivity Disorder, a free handbook
provided by the U.S. Department of
Education, includes effective instructional
strategies for students with ADHD:
https://www2.ed.gov/rschstat/research/
pubs/adhd/adhd-teaching-2008.pdf
Access all ADHD resources on the
Behavioral Health Clinical Program page
of Intermountainhealthcare.net.
This CPM is based on best evidence at the time of publication. It is not meant to be a prescription for every patient. Clinical judgment based on each patient’s unique
situation remains vital.
16 ©2002–2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. (Behavioral Health Clinical Program review 12/16) Patient and Provider Publications 01/17
WORKING WITH SCHOOLS
Teachers play a vital role in the diagnosis and treatment of a child’s ADHD, including:
• Providing key information used in accurately diagnosing ADHD
• Helping implement the child’s management plan, which may include
education accommodations
• Providing ongoing feedback about symptoms and behavior
It’s important that physicians and parents understand the challenges teachers face in
playing these roles, including applicable state laws and guidelines.
Utah guidelines for teacher involvement
Recent (2007) Utah legislation on medical recommendations for children limits how
school staff can participate in behavioral health evaluation and / or treatment. If parents
or teachers receive inaccurate or incomplete information about this legislation, they may
think they are prohibited from providing information about symptoms. Knowing the
facts can help you assist parents as they communicate with school staff. Key highlights
pertaining to ADHD evaluation and communication include:
• Teachers MAY:
–– Provide information and observations to parents about a student’s progress, behavior,
and interactions.
–– Refer a student to a school counselor or other mental health professional within the
school system.
–– If requested by a student’s parent, complete a behavioral health evaluation form.
• Mental health professionals working in the school system ALSO MAY:
–– Recommend (but not require) psychiatric / behavioral evaluation or treatment
for a child.
–– With parental written consent, conduct a psychiatric / behavioral health
evaluation or screening of a child.
–– On request, provide parents with a list of three or more healthcare providers.
• Teachers MAY NOT recommend that a parent seek or use
psychiatric or psychological treatment.
• School system staff (both teachers and health professionals) MAY NOT require that
a student take psychotropic medication. For more information, see the ADHD: Talking
to Your Child’s or Teen’s Teachers fact sheet, described at left.
Laws governing education accommodations for ADHD
Educational accommodations are shaped by two laws (see page 7 for details):
• Section 504 (Rehabilitation Act of 1973). Covers “disability that substantially
limits one or more life activities” (including learning disabilities). If eligible, the
student receives an Accommodation Plan. For students who can benefit from simple
accommodations, qualifying under Section 504 can be easier than IDEA.
• IDEA (Individuals with Disabilities Education Act). Covers “disability that adversely
affects educational performance.” Lists 14 categories for eligibility; ADHD is
included under “Other Health Impairment.” If eligible, a student receives an
Individual Education Plan (IEP) that may include specially designed instruction and
related services. IDEA may be a better choice for students who need more extensive
services or accommodations.