ent Algorithm Psychosocial (behavior) Therapy
> Consider as an initial treatment if: ` Patient's ADHD symptoms are mild with minimal impairment ` Uncertainty of ADHD diagnosis ` Marked disagreement about ADHD diagnosis between parents or parents and teachers
` Preference of family ` Use when presence of comorbid disorder or problem responsive to psychological treatment (eg, CD, ODD, anxiety, depression, substance use disorder)
> Address family dysfunction (eg, parental depression, substance abuse, marital problems)
> Treat any ADHD-affected parent Monitoring Side Effects
> More common: decreased appetite, weight loss, insomnia, headache > Less common: tics, emotional lability/irritability > Adversity of side effect vs. efficacy of medication ` Reduce medication (may affect efficacy) ` Trial of different stimulant/medication class ` Adjunctive medication for side effect ` Trial of nonstimulant medication
> If aggressiveness or emotional lability increases or psychotic symptoms appear, select different medication.
If patient fails to respond to trials of stimulants, review diagnosis of ADHD:
> Accuracy of patient's history > Presence of undetected comorbid conditions (eg, affective, anxiety, subtle developmental disorders) as primary problems impairing attention and impulse control
> Consider conjoint trial of psychosocial (behavior) therapy before trial of other medication
> Consider referral to child and adolescent psychiatrist Results
> Psychopharmacological treatment alone is satisfactory if: ` Robust response to medication ` Normative functioning in academic, family, and social domains
> Psychosocial (behavior) therapy in conjunction with psychopharmacological treatment if: ` Less than optimal response to medication ` Presence of comorbid disorder ` Dysfunction/stressors in family life
> Periodic assessment and follow-up of patient to determine if: ` Medication effective ` Dosage optimal ` Side effects present and clinically significant ` Appropriate growth and weight across major percentiles
> Treatment should continue as long as symptoms remain present and cause impairment 7
