Canadian ADHD Practice Guidelines, 4th Edition - CADDRA (PDF)

 Copyright Notice and Permitted Uses of the Guidelines No material available at www.caddra.ca (the "Materials") may be copied, reproduced, republished, uploaded, posted, transmitted, or distributed in any way, except that you may: (a) Download one copy of the Materials on any single computer for your personal or medical practice use only, provided you keep intact all copyright and other proprietary notices. Where stipulated, specific “tools and patient handouts”, developed for physicians and other medical professionals to use in their practice, may be reproduced by medical professionals or on the advice of medical professionals; (b) Give a presentation using the Materials, so long as: (i) the purpose of the presentation or distribution is for public education; (ii) you keep intact all copyright and other proprietary notices in the Materials; and (iii) the presentation or distribution is completely non-commercial and you or your organization receive no monetary compensation. If monetary compensation is involved, you must provide notice to CADDRA at least ten (10) business days before the presentation and request permission. Modification of the Materials or use of the Materials for any other purpose, without the prior written consent of CADDRA, is a violation of CADDRA's copyright and other proprietary rights. CADDRA Information Current contact details for the Canadian ADHD Resource Alliance (CADDRA) and information on ordering copies of the Canadian ADHD Practice Guidelines are available on the CADDRA website: www.caddra.ca Guidelines Citation The correct citation for this document is: Canadian ADHD Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Fourth Edition, Toronto ON; CADDRA, 2018. French Edition This document is available in French under the title: Lignes directrices canadiennes pour le TDAH, quatrième édition. Feedback Reader suggestions can be provided through our website (www.caddra.ca) or by emailing [email protected] Liability While great effort has been taken to assure the accuracy of the information, the Guidelines Committee, CADDRA and its members, designer, printer and others contributing to the preparation of his document cannot accept liability for errors, omissions or any consequences arising from the use of the information. Since this document is not intended to replace other prescribing information, physicians are urged to consult the manufacturers' product monograph and other available drug information literature before prescribing. Please Note: The CADDRA website (www.caddra.ca) will always have the latest version of the Guidelines available free to download and print. ISBN: 978-0-9738168-4-6 © 2018 Canadian ADHD Resource Alliance (CADDRA)  TABLE OF CONTENTS INDEX OF TABLES AND FIGURES / USB CONTENTS ........................................................................................................... i GUIDELINES EDITORS AND CONTRIBUTORS.................................................................................................................... ii PREFACE......................................................................................................................................................................... 1 CHAPTER 1: DIAGNOSIS OF ADHD................................................................................................................................... 3 CHAPTER 2: DIFFERENTIAL DIAGNOSIS AND COMORBID DISORDERS.............................................................................14 PREVALENCE OF COMORBIDITIES.................................................................................................................................. 14 OPPOSITIONAL DEFIANT DISORDER............................................................................................................................... 16 CONDUCT DISORDER/AGGRESSION............................................................................................................................... 17 ANTISOCIAL PERSONALITY DISORDER............................................................................................................................ 18 BORDERLINE PERSONALITY DISORDER .......................................................................................................................... 19 ADDICTIONS................................................................................................................................................................... 20 SUBSTANCE USE DISORDER ........................................................................................................................................... 20 ANXIETY DISORDERS ...................................................................................................................................................... 21 MAJOR DEPRESSIVE DISORDER...................................................................................................................................... 22 BIPOLAR DISORDER........................................................................................................................................................ 23 DISRUPTIVE MOOD DYSREGULATION DISORDER .......................................................................................................... 24 OBSESSIVE-COMPULSIVE DISORDER.............................................................................................................................. 25 TOURETTE SYNDROME AND TIC DISORDERS ................................................................................................................. 26 EATING DISORDERS........................................................................................................................................................ 26 AUTISM SPECTRUM DISORDER...................................................................................................................................... 27 SPECIFIC LEARNING DISORDER ...................................................................................................................................... 28 SPECIAL PRESENTATIONS............................................................................................................................................... 29 Intellectual Giftedness............................................................................................................................................... 29 Psychological Trauma ................................................................................................................................................ 30 Developmental Coordination Disorder...................................................................................................................... 30 Epilepsy...................................................................................................................................................................... 30 Brain Injury ................................................................................................................................................................ 31 Sleep .......................................................................................................................................................................... 31 Incontinence .............................................................................................................................................................. 32 CHAPTER 3: SPECIAL CONSIDERATIONS ACROSS THE LIFESPAN......................................................................................33 OVERVIEW...................................................................................................................................................................... 33 IMPACT/FUNCTIONAL DISABILITY ACROSS THE LIFESPAN............................................................................................. 37 ACCIDENTS/RISKS........................................................................................................................................................... 38 DRIVING ......................................................................................................................................................................... 39 CHAPTER 4: PSYCHOSOCIAL TREATMENT OF ADHD ......................................................................................................41 PSYCHOEDUCATION ...................................................................................................................................................... 41 PSYCHOSOCIAL INTERVENTIONS OVERVIEW ................................................................................................................ 45 What can be done at home? ..................................................................................................................................... 45 What can be done at school? .................................................................................................................................... 47  What can be done in the workplace?........................................................................................................................ 50 MANUALIZED INTERVENTIONS ..................................................................................................................................... 51 Parent Management Training Models ................................................................................................................... 51 Social Skills Training ............................................................................................................................................... 51 Cognitive Behavioural Therapy .............................................................................................................................. 51 Mindfulness Training.............................................................................................................................................. 52 CHAPTER 5: PHARMACOLOGICAL TREATMENT OF ADHD...............................................................................................53 INTRODUCTION ............................................................................................................................................................. 53 MEDICATION CLASSIFICATION ...................................................................................................................................... 53 First-Line Treatments ............................................................................................................................................. 53 Second-Line Treatments ........................................................................................................................................ 54 Third-Line Treatments............................................................................................................................................ 54 STEPPED APPROACH TO PRESCRIBING.......................................................................................................................... 54 STEP 1 - Setting Treatment Objectives................................................................................................................... 54 STEP 2 - Medication Selection................................................................................................................................ 55 STEP 3 -Titration & Monitoring .............................................................................................................................. 70 STEP 4 - Ongoing Follow-up ................................................................................................................................... 70 MANAGING SIDE EFFECTS ............................................................................................................................................. 71 Common Adverse Events ....................................................................................................................................... 71 When to Reduce the Dose, or Stop a Medication.................................................................................................. 72 How to Stop Medication ........................................................................................................................................ 72 Choosing to Change to a Different Medication...................................................................................................... 73 Side Effects Management Techniques ................................................................................................................... 73 UNSATISFACTORY RESPONSE TO TREATMENT.............................................................................................................. 74 INFORMATION ON SPECIFIC MEDICATIONS.................................................................................................................. 75 Canadian Medication Tables per Age Group.......................................................................................................... 77 Psychostimulants ................................................................................................................................................... 80 Non-Stimulants ...................................................................................................................................................... 87 FREQUENTLY ASKED QUESTIONS ON ADHD MEDICATIONS.......................................................................................... 91 CHAPTER 6: TREATMENTS REQUIRING FURTHER RESEARCH ..........................................................................................93 CONTRIBUTOR DISCLOSURES.........................................................................................................................................96 REFERENCES ..................................................................................................................................................................98  i INDEX OF TABLES AND FIGURES 1.1 Diagnostic and Statistical Manual 5 (DSM-5) Criteria of ADHD Symptoms, 4 1.2 Diagnostic and Statistical Manual (DSM-5) Presentations, 5 1.3 Diagnosis and Treatment – Children, 11 1.4 Diagnosis and Treatment – Adolescents, 12 1.5 Diagnosis and Treatment – Adults, 13 2.1 Prevalence of Comorbidities, 14 2.2 Oppositional Defiant Disorder (ODD) Differentiation, 16 2.3 Conduct Disorder (CD) Differentiation, 17 2.4 Antisocial Personality Disorder (ASPD) Differentiation, 18 2.5 Borderline Personality Disorder (BPD) Differentiation, 19 2.6 Anxiety Disorder Differentiation, 22 2.7 Major Depressive Disorder Differentiation, 23 2.8 Bipolar Disorder (BD) Differentiation, 24 2.9 Disruptive Mood Dysregulation Disorder (DMDD) Differentiation, 25 2.10 Autism Spectrum Disorder (ASD) Differentiation, 27 3.1 Developmental Impact of ADHD, 33 4.1 ADHD Myths, 42 4.2 Interventions at Home, 46 4.3 Interventions at School, 47 4.4 Interventions in the Workplace, 50 5.1 Stepped Approach to Prescribing, 54 5.2 Factors to Consider for ADHD Medication Selection, 55 5.3 Psychiatric and Medical Contraindications and Precautions for ADHD Medications, 59 5.4 Clinical Comparison of Long-Acting Medication, 62 5.5 Drug Interactions - Amphetamines, 63 5.6 Drug Interactions - Methylphenidate, 64 5.7 Drug Interactions – Guanfacine XR, 65 5.8 Drug Interactions – Atomoxetine, 66 5.9 Common Adverse Table, 71 5.10 Second or Third Line Treatment Considerations, 74 5.11 Medical Treatment for ADHD – Children (6-12 Years), 77 5.12 Medical Treatment for ADHD – Adolescents (13-17 Years), 78 5.13 Medical Treatment for ADHD – Adults (18+), 79 5.14 Amphetamine Products, 81 5.15 Methylphenidate Products, 84 5.16 Non-Stimulant Products, 87 Contents of CADDRA ADHD ASSESSMENT eTOOLKIT (USB key) Step-By-Step Guide to ADHD • Diagnosis and Treatment - Children • Diagnosis and Treatment - Adolescents • Diagnosis and Treatment - Adults Assessment, Treatment and Follow-Up Forms • SNAP-IV Teacher and Parent Rating Scale • ASRS (Adult ADHD Self-Rating Scale) • WFIRS-P (Weiss Functional Impairment Rating Scale-Parent) • WFIRS-S (Weiss Functional Impairment Rating Scale-Self) • WSR II (Weiss Symptom Record II) • CADDRA Teacher Assessment Form • CADDRA Clinician ADHD Baseline/Follow-Up Form • CADDRA Patient ADHD Medication Form • CADDRA ADHD Patient Transition Form • JDQ (Jerome Driving Questionnaire) • CADDRA ADHD Assessment Form (optional use) Templates • Educational Accommodation Letter • Employment Accommodation Letter Patient Information • CADDRA ADHD Information and Resources Handout • Instructions for Completing Selected Questionnaires for Health Practitioners Visit www.caddra.ca to access: à ADHD Psychosocial Treatments Chart à ADHD Pharmacological Treatments Chart à Documents in the CADDRA ADHD Assessment Toolkit  ii Canadian ADHD Practice Guidelines The Canadian ADHD Practice Guidelines, 4th Edition, is dedicated to children, adolescents and adults with ADHD, and their families. 4th Edition Guidelines Editors Doron Almagor MD, FRCPC, Director, The Possibilities Clinic, Toronto, ON; Chair, Canadian ADHD Resource Alliance (CADDRA), ON Don Duncan MD, FRCPC, Assistant Clinical Professor, Psychiatry, University of British Columbia, BC Martin Gignac MDCM, FRCPC, Child and Adolescent Psychiatrist; Clinical Associate Professor, Université de Montréal, QC Former Guidelines Editors / Chairs of Guidelines Committee 3rd Edition Umesh Jain MD, DABPN, Ph.D., M.Ed., FRCPC Associate Professor, Psychiatry, University of Toronto, ON Margaret Weiss MD, Ph.D., FRCPC, Clinical Professor, Psychiatry, University of British Columbia, BC Annick Vincent MD, M.Sc., FRCPC Professeur de clinique, département de psychiatrie et de neurosciences, Université Laval, QC 2nd Edition Umesh Jain MD, DABPN, Ph.D. M.Ed., FRCPC Associate Professor, Psychiatry, University of Toronto, ON Attila Turgay MD 1st Edition Umesh Jain MD, DABPN, Ph.D. M.Ed., FRCPC Associate Professor, Psychiatry, University of Toronto, ON External Reviewers 4th Edition Heidi Bernhardt, RN, President and Executive Director, CADDAC (Centre for ADHD Awareness, Canada), Markham, ON Thomas E. Brown, Ph.D., Adjunct Clinical Associate Professor of Psychiatry & Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA James Felix MD, CCFP, University of Victoria Health Services, BC Craig Surman MD, Assistant Professor of Psychiatry, Harvard Medical School, MA; Scientific Coordinator, Adult ADHD Research Program, Massachusetts General Hospital, MA Chris Wilkes MB, IAAP, FRC Psych., Ch.B., DCH, B.Sc., M. Phil., FRCPC Professor, Department of Pediatrics & Psychiatry, University of Calgary, AB 3rd Edition Thomas E. Brown Ph.D., Adjunct Clinical Associate Professor of Psychiatry & Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA Peter S. Jensen MD, President & CEO, The Reach Institute; Professor of Psychiatry, Mayo Clinic, Rochester, MN, USA Sarah Shea MD, FRCPC, Associate Professor, Pediatrics, Dalhousie University, Halifax, NS John Yaremko MD, FRCPC, Assistant Professor, Pediatrics, McGill University, Montreal, QC 2nd Edition Samuel Chang MD, FRCPC, Clinical Associate Professor, Faculty of Medicine, University of Calgary, AB Laurence Jerome MB, Ch.B, M.Sc., FRC Psych., FRCPC, Adjunct Professor, Psychiatry, Western University, ON Annick Vincent MD, M.Sc., FRCPC Professeur de clinique, département de psychiatrie et de neurosciences, Université Laval, QC  iii Authors and Contributors, 4th Edition Chapters Committee Members Affiliation Preface: Doron Almagor MD, FRCPC Director, The Possibilities Clinic, Toronto, ON; Chair, Canadian ADHD Resource Alliance (CADDRA), Toronto, ON Don Duncan MD, FRCPC Assistant Clinical Professor, Psychiatry, University of British Columbia, BC Umesh Jain MD, FRCPC, DABPN, Ph.D., M.Ed. Associate Professor, Psychiatry, University of Toronto, ON Chapter 1: Lauri Alto MD, Ph.D., FRCPC Associate Professor, Pediatrics and Child Health, University of Manitoba, MB Matt Blackwood MD, CCFP, FCFP Family Practitioner, Mission, BC Patricia Ainslie Gray MD Medical Director, Springboard Clinic, Toronto, ON Julia Hunter MD, FRCPC, M.Sc. Psychiatrist, Vancouver, BC Simon-Pierre Proulx MD Groupe de médecins de famille, Loretteville, Québec, QC Declan Quinn MD FRCPC Professor, Psychiatry, University of Saskatchewan, Saskatoon, SK Kristi Zinkiew MD, FRCPC Pediatrician, Mill Bay, BC Chapter 2: Chapter 3: Don Duncan MD, FRCPC Assistant Clinical Professor, Psychiatry, University of British Columbia, BC Martin Gignac MD, FRCPC Child and Adolescent Psychiatrist; Clinical Associate Professor, University of Montreal, QC Andrew Hall MD, FRCPC Assistant Professor, College of Medicine, University of Manitoba, MB Joseph Sadek MD, FRCPC, DABPN, B.Sc. Pharm., MBA Associate Professor, Department of Psychiatry, Dalhousie University, Halifax, NS Sara Binder MD, FRCPC Psychiatrist, Psychiatric Adult Services, Foothills Medical Centre, University of Calgary, AB Natalie Grizenko MD, FRCPC Associate Professor, McGill University; Medical Director of the Severe Disruptive Behaviour Disorders Program and ADHD Clinic, Douglas Mental Health University Institute., QC Chapter 4: Geraldine Farrelly LRCP, LRCSI, DCH (Irel), D.OBST, FRCPC Developmental Pediatrician; Clinical Associate Professor, Pediatrics and Psychiatry, University of Calgary, AB Karen Ghelani, Ph.D., C. Psych Director, Chrysalis Psychological and Counselling Services, Markham, ON; Clinical Adjunct Faculty, York University Psychology Clinic, Toronto, ON Chapter 5: Chapter 6: Doron Almagor MD FRCPC Director, The Possibilities Clinic, Toronto, ON; Chair, Canadian ADHD Resource Alliance (CADDRA), Toronto, ON Sylvie Bourdages, B. Pharm. Pharmacist, Montreal, QC Craig Surman MD Assistant Professor of Psychiatry, Harvard Medical School, MA; Scientific Coordinator, Adult ADHD Research Program, Massachusetts General Hospital, MA Annick Vincent MD, M.Sc., FRCPC Clinique FOCUS, QC; Professeur de clinique, département de psychiatrie et de neurosciences, Université Laval Azadeh Alizadeh Rikani MD, M.Sc., ECFM Ph.D. student, Psychiatric Science, University of Montreal, QC Sylvie Bourdages, B. Pharm. Pharmacist, Montreal, QC Marc Tannous MD Psychiatric Resident, University of Montreal, QC Valerie Tourjman MDCM, FRCPC, Ph.D. Clinical Associate Professor, Department of Psychiatry, University of Montreal, QC  iv Additional Contributors Penny Corkum, Ph.D., R. Psych., Professor, Department of Psychology and Neuroscience, Dalhousie University, NS Samuel Chang MD, FRCPC, Clinical Associate Professor, Faculty of Medicine, University of Calgary, AB Paul Dorian MD, Division of Cardiology (Pediatrics), Hospital for Sick Children, Toronto, ON; Professor of Pediatrics, University of Toronto, ON Lily Hechtman MD, FRCPC, Professor of Psychiatry and Pediatrics, McGill University; Director of Research, Division of Child and Adolescent Psychiatry, McGill University; Director of ADHD Psychiatry Services, McGill University Health Center (MUHC), QC David Goodman MD, FAPA, Assistant Professor, Department of Psychiatry and Behavioral Sciences, John Hopkins School of Medicine, MD Harriet Greenstone, M.A., Ph.D., OPQ, Adjunct Professor, University of Ottawa, ON; Director, Centre MDC, ON Robert Hamilton MD, Division of Cardiology, St. Michael’s Hospital, Toronto, ON; Professor of Medicine and Pharmacology, University of Toronto, ON Laurence Jerome MB, Ch.B., M.Sc., FRC Psych., FRCPC, Adjunct Professor of Psychiatry, Western University, ON Derryck Smith MD, FRCPC, Clinical Professor Emeritus, Psychiatry, University of British Columbia, BC Rosemary Tannock, Ph.D., Professor Emerita and Senior Scientist, University of Toronto, ON Michael Zwiers, R. Psych, Ph.D., Assistant Professor, University of Calgary, AB Editorial Coordinators Anne-Claude Bedard, Ph.D., Assistant Professor, Department of Applied Psychology and Human Development, Ontario Institute for Studies in Education, University of Toronto, ON Amanda Edwards, B.A., Education Coordinator, Canadian ADHD Resource Alliance (CADDRA), Toronto, ON Niamh McGarry, Executive Director, Canadian ADHD Resource Alliance (CADDRA), Toronto, ON Additional Contributors to previous editions: Krista Forand, M.Ed., Calgary Learning Centre, Calgary, AB Rosalia Yoon, Ph.D., Centre for Addiction and Mental Health, Toronto, ON Guidelines and eToolkit Design & Layout: Kim Cheetham and Shee Creative, Sydney, Nova Scotia  1 PREFACE CANADIAN ADHD PRACTICE GUIDELINES INTRODUCTION The purpose of the Canadian ADHD Practice Guidelines is to improve the quality of care and health care outcomes for all individuals with Attention Deficit Hyperactivity Disorder (ADHD) in Canada. The Guidelines: • Cover the lifespan of the disorder. • Are based on published evidence. • Involve expert consensus when there is a lack of evidence. • Offer practical clinical advice. • Provide assessment, treatment and follow-up questionnaires. • Include templates for requesting accommodations. • Recommend optimizing care on an individual basis. • Assist healthcare providers to empower their patients to make informed choices in a collaborative process of care. • Contain information specific to the Canadian healthcare system. The Guidelines are targeted at health care professionals but may also be of use to additional stakeholders (policy makers, funding bodies, educators) and individuals with ADHD and their families. The tools included in the Guidelines were selected based on their validity, reliability and accessibility. These Guidelines were developed to provide information and user-friendly tools to support Canadian health care professionals diagnose and treat ADHD across the lifespan. These Guidelines are not intended to replicate or replace the many excellent textbooks on ADHD. The evolution of the 4th Edition The Canadian ADHD Practice Guidelines are produced and funded by the Canadian ADHD Resource Alliance (CADDRA), a national, independent, not-for-profit association whose members are drawn from family practice, pediatrics, psychiatry (child, adolescent and adult), psychology and other health professions. The Guidelines have been in constant review for over ten years The fourth edition of the Canadian ADHD Practice Guidelines evolved from earlier editions published in 2006, 2008,and 2011. A multidisciplinary team that included ADHD specialists, pediatricians, psychiatrists, psychologists, family physicians, pharmacists, nurses, educators and community stakeholders from across Canada and from the US contributed to its writing and review. Disclosures and Funding Conflicts of interest were recorded for all individuals that were a part of the process and are included in the Guidelines. As it is the case since the 1st edition of the Canadian ADHD Guidelines, all authors have donated their time and shared their expertise without receiving any financial contribution. The final draft of the 4th edition was independently reviewed by a range of relevant stakeholders (e.g. adult psychiatrist, child and adolescent psychiatrist, psychologist, patient advocate/nurse, family physician). The Guidelines development process was fully funded by CADDRA and occurred without external financial grants. Endorsements These Guidelines are endorsed by the Centre for ADHD Awareness, Canada (CADDAC).  2 CADDRA GUIDELINES – CORE PRINCIPLES These Guiding Principles were developed and approved by the CADDRA Board. Principles for Assessment and Diagnosis 1. The clinician has to be fully licensed and adequately trained in order to ensure Diagnostic and Statistical Manual 5 (DSM-5) diagnostic criteria for ADHD are fully met [1]. 2. The assessment needs to reflect an understanding of multi-systemic issues that may confound or complicate the ADHD diagnosis (e.g. the educational/vocational, psychosocial, psychiatric and medical interfaces). 3. Symptoms and functional impairment need to be assessed. Using valid, reliable and sensitive instruments helps to evaluate frequency, severity, and outcome. 4. Regular documentation of symptoms and functional impairment, if possible at each visit, helps to track progress and monitor outcome. 5. Establishing collaborative treatment goals with the patient (and their family when appropriate) ensures that outcomes are patient-centred. 6. The results of the assessment need to be communicated to the patient and their family with clarity and compassion. Abbreviations ADHD Attention Deficit Hyperactivity Disorder DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4th Edition AERS Adverse Event Reporting System DSM-5 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition AMP Amphetamines GXR Guanfacine XR ASD Autism Spectrum Disorder MDD Major Depressive Disorder ASPD Antisocial Personality Disorder MRR Mortality Rate Ratio ASRS Adult ADHD Self Report Scale MPH Methylphenidate ATX Atomoxetine Hydrochloride NF Neurofeedback BD Bipolar Disorder OCD Obsessive Compulsive Disorder BPD Borderline Personality Disorder ODD Oppositional Defiant Disorder CADDRA Canadian ADHD Resource Alliance RCT Randomized Clinical Trials CADDAC Centre for ADHD Awareness, Canada S-ADHD Secondary Attention Deficit Hyperactivity Disorder CBT Cognitive Behavioural Therapy SNAP-IV Swanson, Nolan and Pelham Teacher and Parent Rating Scale CD Conduct Disorder SLD Specific Learning Disorder CHADD Children and Adults with ADHD SUD Substance Use Disorder DCD Developmental Coordination Disorder TS Tourette's Syndrome DEX Dextro-amphetamine WFIRS-P Weiss Functional Impairment Scale – Parent Report DMDD Disruptive Mood Dysregulation Disorder WFIRS-S Weiss Functional Impairment Scale – Self-Report DSM-III Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition WSR-II Weiss Symptom Record II  3 CHAPTER 1: DIAGNOSIS OF ADHD Attention Deficit Hyperactivity Disorder (ADHD) is typically a chronic, often lifelong, condition. The impact and presentation of ADHD can change over time [2] and often requires lifelong monitoring and treatment [3]. Clinicians who follow individual patients and their families should be knowledgeable about how ADHD presents and causes functional impairment across the lifespan. Although the term Attention Deficit Disorder was first introduced in 1980 in the Diagnostic and Statistical Manual of Mental Disorders – 3rd Edition (DSM-III) [4], symptoms of inattention, hyperactivity and impulsivity have been described in children over the last 200 years [5]. A historical perspective reveals that Melchior Adam Weikard is credited with first describing a disorder similar to ADHD in 1775 [6], followed by Sir Alexander Crichton’s description in 1798 [5]; Heinrich Hoffman M.D. created the character of “Fidgety Phil”, used as a popular allegory for children with ADHD, in 1844 [5]; and Dr. George Frederic Still described a condition remarkably similar to ADHD in the English medical journal the Lancet in 1902 [5]. In 1937, psychiatrist Charles Bradley administered Benzedrine sulfate, an amphetamine, to “problem” children at a home in Providence, Rhode Island to alleviate headaches; but noticed an unexpected behavioural effect: improved school performance, social interactions, and emotional responses [7]. The Diagnostic and Statistical Manual of Mental Disorders, 2nd edition (DSM-II) described the disorder “hyperkinetic reaction of childhood (or adolescence)” in 1968 [8]. ADHD is now defined as a neurodevelopmental disorder. Characterization of ADHD has evolved through several revisions over the years, the most recent one being in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) in 2013 [1]. ADHD is usually seen in early childhood, but not necessarily diagnosed at that time. It is thought to be a lifelong disorder. More than 50% of individuals diagnosed in childhood and adolescence continue to have significant and impairing symptoms in adult life [9, 10]. The general prevalence of ADHD is estimated at between 5-9% for children and adolescents and 3-5% for adults [11, 12]. The disorder is not confined to the USA or Canada but is prevalent worldwide [13]. There is a common public misconception, reinforced by much of the media, that ADHD is over-diagnosed. However, a recent meta-analysis confirmed stable rates of the prevalence of ADHD in the past 30 years [14]. The etiology of ADHD remains under investigation. ADHD is highly heritable [15]. Parents with ADHD have a better than 50% chance of having a child with ADHD, and about 25% of children with ADHD have parents who meet the formal diagnostic criteria for ADHD [16]. Twin studies have placed the heritability of ADHD at 76% [17] with the risk of ADHD in first-degree relatives of diagnosed individuals being somewhere between 30 to 40% [18]. This includes children of adults with ADHD, their siblings or their parents. The genetics of ADHD are complex [19]. Many different genes have been identified as linked to ADHD (DRD4, DAT) but as ADHD is a heterogeneous disorder it is most likely related to complex genetic etiologies [17]. The ongoing genome wide studies are likely to shed light on this issue in the future [20, 21]. Other etiological factors have been linked to ADHD, tobacco/alcohol use during pregnancy. Low birth weight and psychosocial adversity should be considered as possible contributors to ADHD symptomatology in an individual [22]. Neuronal networks associated with ADHD have been reviewed in neuroimaging studies and the dysfunction of fronto-striatal pathways (dorsolateral and anterior cingulate) are often targeted as a possible underlying neural mechanism [23]. A landmark study on ADHD, the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study [24], found that 70% of school aged children with ADHD have at least one other psychiatric disorder such as anxiety, Oppositional Defiant Disorder, Obsessive Compulsive Disorder, Tic Disorder or depression.  4 Making a Diagnosis in Primary Care ADHD patients can be managed in a primary care setting [25]. The tasks of diagnosis according to DSM-5 are to ensure: • Current symptoms present sufficiently (see below). • Age of onset of these symptoms is by age 12. • Impairment in two or more roles due to these symptoms is present for the last six months or more. • Lack of alternate explanation for the symptoms or impairment, including a broad range of alternate medical (including mental health) and circumstantial conditions. However, the following situations may require further consultation: • Medical (physical) or psychiatric comorbidities are present and contributing significant morbidity or diagnostic uncertainty (refer to chapter 2). • Failure to respond to recommended treatment algorithms (chapter 5). • Patient/family reluctance to accept diagnosis and/or treatment. Note: Overall psychiatric health should always be considered and a risk assessment done at the onset. There are several tools available to assist in the diagnosis of mental health problems. Examples of these general screeners are the Weiss Symptom Record (WSR)[26], the Patient Health Questionnaire (PHQ-9)[27] and the Generalized Anxiety Disorder Item-7 (GAD-7)[28] as well as the Screen for Child Anxiety Related Disorders (SCARED)[29] and Kutcher Adolescent Depression Scale (KADS)[30]. As always, therapeutic decisions should be based on a thorough evaluation of the patient with the most prominent or critical issues addressed first. This chapter provides information on how to systematically assess patients with features consistent with ADHD. Table 1.1 Diagnostic and Statistical Manual 5 (DSM-5) Criteria of ADHD Symptoms Criteria A1 Inattention Symptoms Criteria A2 Hyperactive-Impulsive Symptoms 1. Often fails to give close attention to details or makes careless mistakes in school work Often fidgets with hands or feet or squirms in seat 2. Often has difficulty sustaining attention in tasks or play activities Often leaves seat in classroom when remaining seated is expected 3. Often does not seem to listen when spoken to directly Often runs about or climbs excessively in situations where it is inappropriate 4. Often does not follow through on instructions and fails to finish school work Often has difficulty playing or engaging in leisure activities quietly 5. Often has difficulty organizing tasks and activities Often is "on the go" or often acts as if "driven by a motor" 6. Often avoids, dislikes, or reluctantly engages in tasks requiring sustained mental effort Often talks excessively 7. Often loses things necessary for activities (e.g. school assignments, pencils, or books) Often blurts out answers to questions before the questions have been completed 8. Often is distracted by extraneous stimuli Often has difficulty awaiting turn 9. Often is forgetful in daily activities Often interrupts or intrudes on others (e.g. butts into conversations/games) Reproduced with permission from American Psychiatric Association Publishing  5 Table 1.2 Diagnostic and Statistical Manual (DSM-5) Presentations Other Specified ADHD / Unspecified ADHD: Symptoms causing impairment but full criteria for ADHD are not met. *Total number of symptoms are less in adults (17+): 5 of 9 instead of 6 of 9 Chapter One of the Canadian ADHD Practice Guidelines and the CADDRA ADHD Assessment Toolkit have been designed to give frontline workers a convenient yet comprehensive step-by-step approach to the assessment and diagnosis of ADHD throughout the lifespan. The forms, assessment tools, and handouts referred to in the diagnostic algorithms are free to download from www.caddra.ca and to print and duplicate for your personal or practice use. Rating scales and questionnaires can be used as an efficient way to obtain information from the patient and collateral sources, but are not sufficient for a diagnosis as other conditions may screen positive on ADHD rating scales (e.g. overlapping symptoms of depression or anxiety or the presence of medical conditions like sleep apnea or anemia). A careful and thorough assessment reduces the risk of a false diagnosis of ADHD [31]. These instruments, however, are effective screening tools and can be employed to document change over time and track treatment effects. Update on strategies for the diagnosis of ADHD Establishing a diagnosis is an essential step in identifying pathology and developing a personalized treatment plan. Thus, clinicians are interested in keeping abreast of advances in diagnostic strategies. To address this need, a review spanning the past 10 years (2006-2016) of the literature diagnosis of ADHD was conducted. Only reviews, meta- analyses and randomized controlled trials were selected. At this time, there is no evidence that any strategies beyond those described in the CADDRA Guidelines and recommended in the toolkit, (namely the clinical interview in combination with rating scales), offer substantial benefit in the diagnosis of ADHD. The clinical interview and evaluation continues to be the mainstay of diagnosis of ADHD. Although rating scales alone cannot be used to diagnose ADHD because of issues such as the variability of interpretation of questions by respondent, their use to enrich the process of evaluation is widely recommended [32]. Direct behavioural observation (i.e. observing the child in the classroom) is recommended by most sources [32, 33], and has been complemented by standardized coding systems. It is associated with a high cost and may be possible where health professionals are part of school personnel [32], but is generally limited to research settings. While, neuropsychological and psychoeducational evaluations are frequently recommended, these are most useful in situations of diagnostic uncertainty [34] and should be interpreted in the context of a broader clinical evaluation given issues of sensitivity and specificity. Certain neuropsychological tests (Wide Range Assessment of Memory and Learning, California Verbal Learning Test, Wisconsin Card Sorting Test) have been recommended as being particularly appropriate measures in ADHD [32]. However, neuropsychological tests of executive function have low ecological validity. Not all individuals with ADHD, although functionally impaired by their ADHD, show impairment levels in test data alone on standardized testing [35-37].  6 Furthermore, testing results should not be required to demonstrate below “average” functioning for a disability to be recognized and for the student to qualify for services and accommodations. Neuropsychological or psychoeducational testing should not be used to determine the severity of ADHD or quantify the impact of ADHD on cognitive or academic functioning as they do not accurately measure the nature of “real world” cognitive or academic impairments that characterize ADHD. Computerized cognitive assessments (e.g. Conners’ Continuous Performance Test, Test of Variables of Attention, Gordon Diagnostic System) have also been developed that specifically assess attention and response inhibition [32] but are associated with a degree of overlap between individuals with ADHD and controls [38]. Neuroimaging has identified structural alterations and dysfunctions in ADHD in population and research studies, but has no direct clinical application at this time [39]. Electroencephalography has been the focus of many publications [40]. Children with ADHD may have an increase in absolute and relative theta and decreases in absolute and relative alpha and beta [40, 41]. This continues to distinguish adolescents and adults with ADHD [40, 41]. Having said this, EEG testing Is not a validated diagnostic tool for ADHD and CADDRA does not endorse its usage for this purpose. Red Flags for ADHD [3, 42-44] • Organizational skill problems (time management difficulties, missed appointments, frequent late and unfinished projects). • Erratic work/academic performance. • Anger control problems. • Family/marital problems. • Difficulty in maintaining organized household routines, sleeping patterns and other self-regulating activities. • Difficulty managing finances. • Addictions such as substance use, compulsive shopping, sexual addiction, overeating, compulsive exercise, video gaming or gambling. • Frequent accidents either through recklessness or inattention. • Problems with driving (speeding tickets, serious accidents, license revoked). • Having a direct relative who has ADHD. • Having to reduce their course load, or having difficulty completing assignments in school. • Low self-esteem or chronic under-achievement.  7 STEP 1: INITIAL INFORMATION GATHERING Reasons for Assessment or Referral Individuals may come to you, or are referred, for a wide variety of reasons: • Someone close to the individual (e.g. a relative, teacher, employer, colleague or friend) has learned about ADHD and recognizes these traits in the person. • The individual (typically an adolescent or an adult) has learned about ADHD and recognizes the relevant symptoms. • A relative has already been diagnosed with ADHD and this diagnosis triggers an awareness of ADHD within the individual (e.g. a child is diagnosed and one or both parents think they may also have ADHD). • There are functional difficulties that the individual presents with (such as behavioural or attention problems, academic issues, difficulty with paperwork, time management, driving, smoking or marital problems) and the clinician postulates ADHD as a possible explanation. • Symptoms are attributed to another psychiatric diagnosis (mania, depression, anxiety, substance use disorder) but in fact could be related to ADHD. Some clinicians may be wary of an individual self-referring with a possible ADHD diagnosis. They may suspect that the person is looking for drugs, accommodations or an explanation/excuse for other problems. Clinical experience indicates this is an infrequent occurrence. Practice Point • Review the individual’s strengths and NOT just their areas of relative weakness. • Establish a rapport with the individual and their family that makes future contacts easier and can aid intervention planning. • Ensure that each interview ends with a statement about the coping skills that the individual and/or family have successfully used to work with difficult circumstances. • Outline and affirm the importance and value of the individual and their family’s efforts to succeed. • Remember that self-referral neither guarantees nor eliminates a diagnosis of ADHD. Presenting Complaint and Documentation Initiation Review with the individual and their family any concerns, the reason(s) for referral and the individual’s/family’s hopes for the assessment. Psychometric evaluations included in the CADDRA toolkit are designed to track the person’s progress and assist with efficient and structured clinician charting. The diagnosis of ADHD cannot be done through the CADDRA toolkit alone but in conjunction with a diagnostic interview and attention to medical history, psychosocial elements and clinical presentation. SUGGESTED ACTION - AT THE END OF STEP 1 • Give the individual the relevant inventories necessary for the next visit (see appropriate ‘Diagnosis and Treatment Flowchart’ for the age group). • Ask the individual and/or family to provide any relevant prior documentation (e.g. school report cards, previous assessments, etc.). Good school performance does not necessarily rule out ADHD. Individuals with ADHD may not accurately recall symptoms [45]. Therefore, collateral information may assist in diagnosis.