ADHD Clinical Reference Guide
Clinical Reference School Psychology & Multidisciplinary IEP/504 Guidance
ADHD Diagnostic, Pharmacological & Clinical Matrix
DSM-5-TR / ICD-11
Page 1 of 2 • Diagnostics & Rx
1. Diagnostic Criteria & Tools Across Populations
Thresholds Across the Lifespan
- Pediatric (<17): \(\ge 6\) inattentive and/or hyperactive-impulsive symptoms; \(\ge 2\) settings prior to age 12 with impairment.
- Adults (\(\ge 17\)): \(\ge 5\) symptoms; motor hyperactivity shifts to internal restlessness and cognitive disorganization.
- ICD-11 Lifespan: Prioritizes developmental manifestations over rigid counts; permits adult diagnosis via historical impairment.
Masking & Special Populations
- Females / High Maskers: Predominantly inattentive traits, internalized distress, and masking; evaluate internal chaos and chronic exhaustion.
- Older Adults: Differentiate lifelong executive dysfunction from Mild Cognitive Impairment (MCI) via rating scales and cognitive tests.
| Target Group | Validated Instruments | Psychometric & Clinical Focus |
|---|
| Pediatric (K-12) | Conners 4, Vanderbilt Scales, SWAN | SWAN measures strengths and deficits; multi-rater cross-setting data. |
| Adults (\(\ge 17\)) | ASRS-5, CAARS, DIVA-5 | DIVA-5 semi-structured interview compares childhood vs adult symptoms. |
| High Masking / Females | DIVA-5 (modified clinical probe), BRIEF-2 | Probes compensatory perfectionism, executive overload, and emotional strain. |
2. Pharmacotherapy Matrix (Current, Novel & Emerging)
| Class | Key Drug Formulations | Mechanism, Dosing & Clinical Utility |
|---|
| Extended-Release Stimulants | Jornay PM (MPH ER) | |
| Azstarys (SDX / d-MPH) | | |
| Vyvanse (Lisdexamfetamine) | Jornay PM: Evening dosing for morning control upon awakening. | |
| Azstarys: Serdexmethylphenidate prodrug + d-MPH for smooth, sustained coverage. | | |
| Vyvanse: Prodrug with low misuse liability; dual FDA indication for BED. | | |
| Selective NRIs (Non-Stimulants) | Atomoxetine (Strattera) | |
| Viloxazine ER (Qelbree) | Selective norepinephrine reuptake inhibitors with zero abuse potential. Qelbree: Serotonergic modulation (\(5\text{-HT}_{2B}\) antagonism / \(5\text{-HT}_{2C}\) agonism); approved for children and adults. | |
| Alpha-2 Agonists (Non-Stimulants) | Guanfacine ER (Intuniv) | |
| Clonidine ER (Onyda XR) | Modulates prefrontal cortex networks. Onyda XR: Once-daily liquid extended-release; ideal for swallowing difficulties, nighttime hyperactivity, and comorbid tics. | |
| Triple Reuptake Inhibitor (Emerging) | Centanafadine (NDSRI) | |
| Investigational Phase III | First-in-class NE, DA, and 5-HT reuptake inhibitor. Shows broad efficacy in pediatric/adult trials with low abuse liability and marked reduction in comorbid anxiety. | |
3. ADHD & Co-Occurring Substance Use Disorder (SUD)
Prevalence & Risk
Prevalence: \(15\% - 25\%\) in adult SUD treatment cohorts.
ADHD confers a \(2\text{--}3\times\) higher lifetime risk of developing SUD due to impulsivity and self-medication.
CADDRA / APSARD Sequencing
Severe SUD: Medical stabilization and detox take immediate precedence.
Mild/Mod SUD: Treat concurrently to remove impulsivity triggers that drive relapse.
Safe Prescribing Choices
Preferred: Prodrug ER stimulants (Lisdexamfetamine) or non-stimulants (Atomoxetine, Viloxazine).
Avoid immediate-release stimulants due to euphoric peak and diversion risks.
Guidelines: DSM-5-TR, ICD-11, CADDRA 5th Edition, APSARD Consensus ADHD Clinical Reference • Page 1 of 2
Clinical Reference Behavioral Interventions & Family Systems
Adolescent Autonomy, Sleep, Nutrition & Family Systems
Systems & Interventions
Page 2 of 2 • Behavioral Protocols
4. STAND Adolescent Model (Dr. Margaret Sibley)
Core Mechanisms
- Motivational Interviewing (MI): Embedded across all sessions to dismantle resistance, address ambivalence, and build intrinsic motivation.
- Parent-Teen Collaboration: Replaces unilateral control with joint problem-solving, structured home contracts, and negotiated autonomy.
Modular Framework (15 Modules)
Engagement (4): Therapeutic alliance, goal alignment, and psychoeducation.
Skill-Building (7): OTP mastery (Organization, Time Management, Planning, planner systems).
Mobilization (4): Routine automation, independent maintenance, relapse prevention.
5. Melatonin & Sleep Interventions (DSPS Management)
Etiology & DSPS
Up to \(75\%\) experience Delayed Sleep Phase Syndrome (DSPS) or sleep-onset insomnia driven by delayed endogenous melatonin release and cognitive hyperarousal.
Behavioral Chronotherapy
- • Morning bright-light exposure (\(10{,}000\text{ lux}\)).
- • Consistent sleep schedule aligned with chronotype.
- • Calibrate stimulant timing to eliminate evening medication rebound.
Melatonin Dosing Protocol
Dose: Low dose (\(0.5\text{ mg} - 3\text{ mg}\)).
Timing: \(30\text{--}60\text{ min}\) prior to bedtime, or \(2\text{--}3\text{ hrs}\) prior for circadian phase shift. Always pair with behavioral sleep hygiene.
6. ADHD & Eating Disorders (BED & Bulimia Nervosa)
Predisposing Factors
- Dopamine Seeking: Craving palatable foods to compensate for deficient reward circuitry.
- Interoceptive Deficits: Impaired awareness of hunger/fullness cues until extreme hunger triggers a binge.
- Rebound Re-feeding: Daytime stimulant appetite suppression leading to severe late-night binge episodes.
Clinical Interventions
- Mechanical Eating: Clock-scheduled planned meals/snacks that bypass reliance on interoceptive cues.
- Pharmacotherapy: Lisdexamfetamine is FDA-approved for both ADHD and moderate-to-severe BED.
- CBT Adaptations: Focus on emotional regulation and impulse inhibition.
7. Multiplex ADHD Family Dynamics (\(70-80\%\) Heritability)
Systemic Challenges
- Synergistic EF Deficits: Shared parental and child disorganization impairs routine tracking and medication consistency.
- Emotional Cascades: Bi-directional dysregulation quickly escalates household conflict.
- Treatment Non-Adherence: Missed sessions and abandoned reward charts due to memory load.
Opportunities & Dual-Generation Care
- Shared Empathy: Deep mutual understanding dismantles shame and validates neurodivergence.
- Synchronized Systems: Family-wide visual hubs and automated alerts support all members simultaneously.
- Dual-Generation Treatment: Managing parental ADHD directly improves parenting consistency and child outcomes.
Frameworks: Sibley STAND Protocol, AASM Chronotherapy, AACAP Practice Parameters ADHD Clinical Reference • Page 2 of 2
STAND Method Implementation Guide
Evidence-Based Model Dr. Margaret H. Sibley • Adolescent ADHD Intervention
STAND: Supporting Teens' Autonomy Daily
Clinical & School Guide
Page 1 of 2 • Core Architecture
Core Clinical Rationale: Adolescents with ADHD experience a developmental clash between their emerging drive for independence and underlying executive dysfunction (EF). Traditional top-down behavioral management often breeds parental exhaustion and teen defiance. STAND replaces unilateral control with collaborative autonomy, blending Motivational Interviewing (MI), OTP (Organization, Time Management, Planning) training, and negotiated behavioral contracts.
1. The Three Core Pillars of STAND
Pillar I: MI Engine
Integrated across every session to roll with adolescent resistance, explore ambivalence, and elicit the teen's own core values and internal goals.
"What part of your current study routine is getting in the way of what you want?"
Pillar II: Parent-Teen Dyad
Shifts caregivers from monitors/enforcers to supportive scaffolding partners through structured, non-punitive contract negotiations.
Autonomy is granted in direct alignment with objective EF routine demonstration.
Pillar III: OTP Skills
Explicit, manualized coaching in Organization, Time Management, and Planning tailored to the teen's natural workflow and tech preferences.
Focuses on tangible routines: backpack staging, master planners, task chunking.
2. 15-Module Modular Architecture (3-Tier Progression)
| Progression Tier | Modules & Focus | Clinical Objectives & Deliverables |
|---|
| Tier 1: Engagement | | |
| Modules 1 – 4 | • Therapeutic Alliance | |
| • ADHD & EF Psychoeducation | | |
| • Values & Goal Consensus | | |
| • Establishing the "Ground Rules" | Establish trust with teen; align long-term aspirations (e.g., driver's license, gaming, independence) with daily habits; demedicalize ADHD deficits as EF friction points. | |
| Tier 2: Skill-Building | | |
| Modules 5 – 11 | • Organization Hub / Backpack | |
| • Master Planner / LMS Capture |
