1.
When ADHD gets complex
Olaf Kraus de Camargo
@DevPeds
Credit: SDBP slides by Michele Ledesma, MD

2.
Outline
§ Example
§ CPS Statement
§ ADHD Research
§ Complex ADHD Guideline (SDBP) and how it applies to case
§ Application to RJCHC case load

3.
March 2020
§ Current concerns:
§ 6 yo girl, comes with grandmother who is caregiver
§ Concerns with learning and applying knowledge as she is seen as forgetful and
often busy, moving from task to task
§ Teacher believes she is behind her peers in terms of reading and writing, and
is difficult to teach due to lack of focus
§ Her toileting and hygiene behaviour is concerning as she often is found to be
unhygienic with feces found in her clothing or on a toilet seat (one incident
mentioned where feces was found smeared on the walls of the bathroom)
§ Often is found having hurt other children in class or having hurt her own
sister

4.
Conners - Teacher
The Inconsistency Index score (raw score = 9,
number of differentials ≥ 2 = 2) indicates that
responses to similar items showed high levels
of inconsistency. Scores may not accurately
reflect the individual due to a careless or
unusual response to some items.

5.
Conners - Grandmother
The Inconsistency Index score (raw score = 8,
number of differentials ≥ 2 = 2) indicates that
responses to similar items showed high levels
of inconsistency. Scores may not accurately
reflect the individual due to a careless or
unusual response to some items.

6.
CPS – ADHD - Diagnosis
1. “Symptoms are severe, persistent (i.e. present before 12 years of age and
continuing > 6 months), and inappropriate for the patient’s age and
developmental level”
2. “Symptoms are associated with impairment in academic achievement,
peer and family relations and adaptive skills”
Bélanger SA,Andrews D, Gray C, Korczak D. ADHD in children and youth: Part 1 - Etiology, diagnosis, and
comorbidity. Paediatr Child Heal. 2018;23(7):454-461. doi:10.1093/pch/pxy110

7.
CPS – ADHD - Process
1. Schedule several office visits to complete the diagnostic
evaluation
2. Obtain detailed information on prenatal/perinatal events,
medical and mental health history
3. Obtain developmental/behavioural history
Bélanger SA,Andrews D, Gray C, Korczak D. ADHD in children and youth: Part 1 - Etiology, diagnosis, and
comorbidity. Paediatr Child Heal. 2018;23(7):454-461. doi:10.1093/pch/pxy110

8.
CPS – ADHD - Process
4. Evaluate family medical and mental health needs, family
functioning and coping styles of primary caregivers.Ask
about genetic disorders
5. Evaluate for comorbid disorders (psychiatric,
neurodevelopmental and physical)
6. Review academic progress
7. Obtain standardized behaviour rating scales
Bélanger SA,Andrews D, Gray C, Korczak D. ADHD in children and youth: Part 1 - Etiology, diagnosis, and
comorbidity. Paediatr Child Heal. 2018;23(7):454-461. doi:10.1093/pch/pxy110

9.
Findings in March 2020
§History:
§There may have been prenatal exposure to crystal meth,
alcohol, cocaine
§Girl received services for speech delay when she was little
§Grandmother believes that there has been exposure to
sexually explicit content and physical abuse between
parents.There is also a concern that the children were
given access to cocaine at a younger age by the biological
mother

10.
Findings in March 2020
§Family History:
§ Strong family history of Learning Disability,ADHD, Intellectual
Disability,Tic Disorders, "Rage Disorder", Sleeping Disorder

11.
Findings in March 2020
§Supports in school environment:
§No services in place to help her focus at school (IEP or
EA)

12.
Findings in March 2020
§Supports in home environment:
§ A sister (who was also assessed and presents with similar issues) and paternal
aunt (who has an intellectual disability) in the home, along with 10 dogs
(multiple adult dogs and multiple puppies). CAS is involved and has concerns
about the cleanliness of the house.
§ No services in place to help grandmother with behavioural challenges of 2
girls that have been exposed to a series of stressors over the last 6 years and
might present with FASD/ACE’s

13.
Findings in March 2020
§Physical Exam & Observation:
§ Normal physical exam, 2 of 3 sentinel facial features for FASD
§ Compliant, friendly, not restless during consult

14.
CPS – ADHD - Diagnosis
Bélanger SA,Andrews D, Gray C, Korczak D. ADHD in children and youth: Part 1 - Etiology, diagnosis, and
comorbidity. Paediatr Child Heal. 2018;23(7):454-461. doi:10.1093/pch/pxy110

15.
CPS – Recommendations
§Co-morbid ASD, ID, prematurity?
§Does not fulfil diagnostic criteria for any of
those
§“Coordinated therapies help to lower the
medication dose required and minimize risk for
adverse effects.”
Clark B, Bélanger SA.ADHD in children and youth: Part 3-Assessment and treatment
with comorbid ASD, ID, or prematurity. Paediatr Child Heal. 2018;23(7):485-490.
doi:10.1093/pch/pxy111

16.
CPS – ADHD - Treatment
§ Non-pharmacologic
interventions
1. Psychoeducation
2. Shared decision-making
3. Parent Behaviour Training
4. Classroom Management
5. Daily Report Card
6. Behavioural Peer Interventions
7. Organizational Skills Training
8. Exercise
§ Pharmacologic interventions
1. Stimulants
2. Non-stimulants
Feldman ME, Charach A, Bélanger SA.ADHD in children and youth: Part 2—Treatment.
Paediatr Child Heal. 2018;23(7):473-484. doi:10.1093/pch/pxy114

17.
CPS – Recommendations
1. “Treatment approaches for children and youth with
ADHD and comorbidities must be multimodal and
part of an individualized, comprehensive care plan.A
psychoeducational plan of interventions should
be initiated first, combined with other
nonpharmacological interventions and medication
when indicated, always keeping specific functional or
behavioural goals in mind.”
Feldman ME, Charach A, Bélanger SA.ADHD in children and youth: Part 2—Treatment.
Paediatr Child Heal. 2018;23(7):473-484. doi:10.1093/pch/pxy114

18.
CPS – Recommendations
2. “Medication use should be reserved for children
and youth diagnosed with ADHD whose learning
or academic performance are impaired by
attention difficulties or whose behaviours and
social interactions are impaired by lack of
impulse control and hyperactivity.”
Feldman ME, Charach A, Bélanger SA.ADHD in children and youth: Part 2—Treatment.
Paediatr Child Heal. 2018;23(7):473-484. doi:10.1093/pch/pxy114

19.
CPS – Recommendations
3. “When initiating treatment with ADHD
medication, set goals or target outcomes
focused on symptom reduction and
improved functioning to guide the
treatment plan.”
Feldman ME, Charach A, Bélanger SA.ADHD in children and youth: Part 2—Treatment.
Paediatr Child Heal. 2018;23(7):473-484. doi:10.1093/pch/pxy114

20.
Plan in March 2020
§ Refer to behavioural services due to described challenges in the
home environment and overwhelmed grandmother
ØServices for BT declined due to lack of diagnosis of ID
ØReferral to Contact Hamilton
What about meds?

21.
ADHD - Research
Pelham WE,Altszuler AR. CombinedTreatment for Children with Attention-Deficit/ Hyperactivity
Disorder: Brief History, the Multimodal Treatment for Attention-Deficit/Hyperactivity Disorder Study,
and the Past 20Years of Research. J Dev Behav Pediatr. 2020;41(2):S1-S11.
What about different dosages?
With behaviour therapy less
medication is required

22.
ADHD - Research
Pelham WE,Altszuler AR. CombinedTreatment for Children with Attention-Deficit/ Hyperactivity
Disorder: Brief History, the Multimodal Treatment for Attention-Deficit/Hyperactivity Disorder Study,
and the Past 20Years of Research. J Dev Behav Pediatr. 2020;41(2):S1-S11.
In what order and which combination should we treat?

23.
ADHD - Research
Pelham WE,Altszuler AR. CombinedTreatment for Children with Attention-Deficit/ Hyperactivity
Disorder: Brief History, the Multimodal Treatment for Attention-Deficit/Hyperactivity Disorder Study,
and the Past 20Years of Research. J Dev Behav Pediatr. 2020;41(2):S1-S11.
Better start with BT!

24.
< 4 years
Presentation at age > 12 years
Age
Complex ADHD
Developmental/learning issues
Medical diagnoses
Psychiatric diagnoses
Co-occurring conditions
Moderate to Severe
Functional Impairment
Diagnostic uncertainty
Inadequate response to
treatment
Any of the following:

25.
What about your clients?

26.
Complex ADHD
Children and adolescents with ADHD
can have moderate-to-severe
impairment across settings
• Academics
• Family functioning
• Peer relationships
• Extracurricular activities
Approximately 1/2 to 2/3 will have a
co-occurring condition

27.
Complex ADHD Guideline:
Highlights
A focus on functional impairment to improve
long term outcomes
A focus on evidence-based psychosocial
interventions as the foundation of treatment
for complex ADHD

28.
Complex ADHD Guideline:
Highlights
Shared decision making and clinical judgement
Interprofessional care
Comprehensive assessment, including psychological
testing and mental health diagnostic assessment
Multimodal treatment, including treating co-
occurring conditions
A life-course perspective

29.
MANAGEMENT
Evidence-based behavioral and educational
interventions are the foundation of treatment.
These address key functional domains (behavioral,
educational, social) in home, school, and peer settings
that are associated with improved long-term outcomes.

30.
MANAGEMENT
Developmentally-appropriate strategies for self-
management, skill building, and prevention of adverse
outcomes should be incorporated:
• Behavior parent training (BPT)
• Behavioral classroom management (BCM)
• Behavioral peer intervention (BPI)
• Organizational skills training for older children

31.
MEDICATION MANAGEMENT
COMBINED INTERVENTION WITH MEDICATION MANAGEMENT IS
OFTEN INDICATED
Clinicians should consider both symptoms and functional impairment.
• Treatment goals should focus on functional impairment, not solely on symptom
reduction.
For significant co-occurring conditions, particularly mental health diagnoses,
clinical judgment should be used to select treatment based on the symptoms that
most impact functioning.

32.
PROCESS-OF-CARE ALGORITHMS
Behavioral/Educational
Treatment
(age ≥ 6 years)
General Medication
Treatment
(age ≥ 6 years)
Preschool General
Medication Treatment
(age 3-6y)

33.
PROCESS-OF-CARE ALGORITHMS
ADHD + Autism ADHD + Tics ADHD + Anxiety
ADHD + Disruptive Behavior
Disorders
ADHD + Depression ADHD + Substance Use
Disorder

34.
ADHD and Coexisting Disruptive Behavior Disorders
Child with ADHD and Disruptive Behaviors Disorder (DBD)
• Evaluate current services and supports, ensure that
basic behavioral/educational treatment has been
implemented (see Behavioral/Educational Treatment
of Complex ADHD Algorithm)
• Implement intensive, evidence-based behavioral
treatment (e.g., multi-systemic therapy, wrap-around
services, intensive special education supports and
setting
• Monitor response
Is impairment from
DBD severe?
• Adapt high intensity behavioral treatment if
necessary or return to basic
behavioral/educational interventions
• Consider pharmacological treatment (see
Complex ADHD General Medication Treatment
Algorithm)
To Behavioral/Educational
Treatment of Complex ADHD
Algorithm
Yes
Yes
No
Is impairment from
DBD still severe?
• Continue intensive behavioral
treatments and supports
• Go to Behavioral/Educational
Treatment of Complex ADHD
Algorithm.
No
Barbaresi WJ, Campbell L, Diekroger EA, et al. The Society for
Developmental and Behavioral Pediatrics Clinical Practice Guideline for
the Assessment and Treatment of Children and Adolescents with
Complex Attention-Deficit/Hyperactivity Disorder: Process of Care
Algorithms. J Dev Behav Pediatr. 2020;41 Suppl 2S:S58-S74.
doi:10.1097/DBP.0000000000000781

35.
MANAGEMENT
Communication and coordination of care among all
professionals involved in the treatment and
management of children and adolescents with complex
ADHD is of utmost importance.
Interventions often require targeted referral to
behavioral health providers.

36.
LONG-TERM CARE
ONGOING, SCHEDULED MONITORING
THROUGHOUT THE LIFE SPAN
Preparing for key
developmental
transitions ADHD symptom severity
Symptoms of co-existing conditions
Functional impairment
Standardized
questionnaires
2-4x/year
Screening for emerging
co-existing conditions at
least annually

37.
LONG-TERM
CARE
MEDICATION MANAGEMENT
Monitor therapeutic & side
effects of medications within the
first 30 days
Medication management visits
at least every 3-4 months
Review anthropometric
measures & cardiovascular
indices that can be affected by
medication

38.
Status October 2020
§ Contact Hamilton called once in the summer and then did not
connect anymore
§ Behaviours escalating at home
§ Report card from grade 1 (6 years):
§ “completes tasks when 1:1 support. Knows five letters of the alphabet and one
sound, some understanding of numbers, counts to 20, skipping 13 and 15, can
represent quantities using blocks up to 7. Often refuses to participate in Gym.”
§ Still no services at home or at school
Over 4 years in the “System”!

39.
Complexities
§ Complex presentation of ADHD
§ Breakdown of interprofessional communication and collaboration
§ Siloed service structures
§ Funding-centred services X Family-centred care (needs-based)

40.
Case Load RJCHC – “ADHD”
§ 2019-2020:
§ About 600 children and adolescents with ADHD (DPR + CYMH)
§ Medication management every 4 months:
§ Need for 1800 visits w/nursing and/or physician
§ One full-time physician has about 360 FU spots/year
ØGuideline-conforming ADHD management would require 5 full-time staff only
for medication management

41.
Case Load RJCHC – “ADHD”
§ 2019-2020:
§ about 600 children and adolescents between DPR and CYMH
§ Behaviour management:
§ Ex. BPTG@HOME: 15 home visits/family/year – 50% of patients
§ Need for 4500 visits with therapists (BT and/or SW)
ØGuideline-conforming ADHD management would require ?? full-time staff
only for behavioural management (if one staff offers about 900 visits/year – 10
staff)
Nobel E, Hoekstra PJ,Agnes Brunnekreef J, et al. Home-based parent training for school-aged children
with attention-deficit/hyperactivity disorder and behavior problems with remaining impairing disruptive
behaviors after routine treatment: a randomized controlled trial. Eur Child Adolesc Psychiatry.
2020;29(3):395-408. doi:10.1007/s00787-019-01375-9

42.
Solutions
§ Focus on funding clinical staff
§ Improve collaboration with community-based services and schools
§ Obtain synergies from joint documentation across service providers
(patient-owned health record)
§ Monitor and assess behaviours and side-effects online for time-
efficient and targeted actions

43.
Example -eHealth

44.
Q & A Session
Q A&
ThankYou!